Please complete this application before attending the PEP Program in your area.  All information collected is considered confidential and will only be used for the purposes of communicating with you and supporting your participation in the PEP Program. Your information will not be sold or used for any other purposes. Thank you! 

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* 2. Type of PEP Program

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* 5. My Contact Information

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* 6. I am also registering my partner or significant other for the PEP Program

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* 7. If applicable, please provide the contact information for your partner or significant other

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* 8. What best describes you?

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* 9. If you describe yourself as a parent, what is the age of your child with the serious medical condition?

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* 10. Name of Medical Center, Hospital, or Treatment Center

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* 11. How did you hear about PEP?

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* 12. Why do you want to attend PEP?

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* 13. Photographic & Publicity Release: 
I give permission for Energizing and Empowering Mind (EEM), the administrator of the Parents Empowering Parents (PEP) program, to

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* 14. Each participant must agree to EEM's PEP Program Participant Confidentiality and Copyright Agreement. This link allows you to access the Agreement and read it; you may also print a copy for your records.
By Clicking the I agree box below, you are providing your electronic digital signature and confirmation of your agreement to the terms.

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* 15. Homecare/Industry Conflict of Interest Note: The policy guidelines for the PEP program state that parents employed by industry may (1) attend their local PEP program as the parent of a child with the medical condition, but (2) may not become a PEP parent trainer, as this would be put them at risk for conflicts of interest.

Are you or anyone in your immediate family employed by a pharmaceutical company or home healthcare company associated with your child's condition? 

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* 16. We appreciate your cooperation following these PEP program’s policies.
**Please acknowledge you have read the above by inserting today's date and time:

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