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* 1. Your name

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* 2. How would you like to be involved in our program?

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* 3. Message:

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* 4. What is your role?

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* 5. Name of organisation or N/A if not applicable

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* 6. Contact Email Address

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* 7. Contact Phone Numner

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* 8. Suburb

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* 9. Preferred Contact Day/s and Time/s

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* 10. How did you hear about Community Minded Kids

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* 11. Other:

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