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* 1. What is your name?

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* 2. Contact information:

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* 3. Are you affiliated to a Youth MOVE Chapter? 

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* 4. Which best describes your main role?
[choose one]

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* 5. What type of assistance are you requesting?

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* 6. What is the area of the assistance you are requesting?
Please select up to three priority areas.

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* 7. In one or two sentences, what is the topic of your request?
A Youth MOVEr will follow up for additional details, if needed.

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* 8. Are you affiliated with any of the following initiatives?

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* 10. Do you have any additional comments?

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