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* 1. Name

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* 2. Year of birth (enter 4-digit birth year; for example, 1976)

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* 3. Gender

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* 4. Race/Ethnicity

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* 5. Headshot

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* 6. Current Employer

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* 7. Occupation/Title

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* 8. Home Contact Information

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* 9. Preferred Contact Information (if different from above)

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* 10. Emergency Medical Contact Person

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* 11. To ensure accurate application of your payment, please note below any other name or entity that may be associated with your ENCOUNTER tuition. If none, please put N/A.

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* 12. I would be interested in learning about scholarship opportunities for ENCOUNTER.

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* 13. How did you hear about ENCOUNTER Charlotte?

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* 14. How long have you lived Charlotte?

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* 15. Where did you previously live?

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* 16. Why did you relocate to Charlotte?

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* 17. What are the top three Charlotte leadership areas you would like to know about?

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* 18. What are your current (or previous) volunteer interests?

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* 19. Do you have any food allergies or dietary restrictions?

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