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* 1. Your Name (First and Last)

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* 2. Home Address (Full Mailing Address)

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* 3. Phone Number

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* 4. Email

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* 5. I identify my gender as:

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* 6. Please indicate your age range:

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* 7. Please tell us if you self-identify with any of the following:

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* 8. What is the highest degree or level of school you have completed?

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* 9. Which of the following best describes the type of community that you live in?

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