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* 1. Today's Date

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* 2. Your Name

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* 3. Address-Street/Town/Zip:

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* 4. Email Address

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* 5. Names, Ages of Children 

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* 6. Phone Number

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* 7. Age of your most challenging child?

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* 8. Which Workshop do you want to attend?

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* 9. How did you hear about these workshops?

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