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* 1. First Name

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* 2. Last Name

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* 3. Do you meet these qualifications for a free membership?

· A student OR

· In need for financial help OR

· Be a new member (or lapsed member from 2 years prior)

· Must attend three meetings initially

· Must attend at least 3 meetings after receiving said membership

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* 4. Email Address

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* 5. Who referred you? (You can right N/A if its no one)

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