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* 1. First Name

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* 2. Last Name

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* 3. What are your pronouns?

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* 4. Gender Identity (select all that apply)

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* 5. Orientation (ex: Ace, Bi, Gay, Lesbian, Pan, etc.)

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* 6. What is your race/ethnicity? (Check all that apply)

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* 7. Age range

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* 8. Email Address

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* 9. Phone Number

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* 10. City, State of Residence

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* 11. Zip Code of Residence

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* 12. What is your health and wellness story? (maximum 200 words)

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* 13. Why do you want to tell your story? 

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* 14. If chosen, can you commit to presenting between October 14-15?

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* 15. Is there anything else you would like our team to know about you?

0 of 15 answered
 

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