Join Shiprock JMI 2020!

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* 1. Full Name

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* 2. Address - PO Box or Street

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* 3. What Community do you currently live in?

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* 4. Gender ?

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* 5. Age Group

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* 6. How Many of your CLANS do you know

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* 7. Do you have diabetes?

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* 8. In a typical week, how many days do you do at least 30 minutes of physical activity? (some examples: walking, hiking, jogging, chopping wood, bike riding, or gardening)

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* 9. On a typical day, how many FRUITS & VEGETABLES do you eat? *

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* 10. On a typical day, how many cans of REGULAR POP or SWEETENED FRUIT DRINKS do you drink (44oz = 3 1/2 cans)

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* 11. On a typical day, how many hours do you watch TV, play VIDEO GAMES, use the COMPUTER, or watch on your PHONE? (do not include school or work hours)

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* 12. How would you like us to keep in contact with you? (check all that apply)

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