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* 1. First Name:

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* 2. Last Name:

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* 3. Phone Number:

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* 4. E-Mail Address:

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* 5. Mailing Address:

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* 6. What is your 5-digit zipcode?

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* 7. Age:

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* 8. I consent to receive phone calls, emails and/or text messages from both Central Florida Basketball Partners, LLC d/b/a Lakeland Magic and Blue Cross and Blue Shield of Florida, Inc. at the contact information that I have submitted, including my wireless number if provided. I understand these communications may be generated using automated technology.

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