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* 1. Please list your first and last name.

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* 2. What is your email address?

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* 3. What is your phone number?

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* 4. If part of an organization please provide the name of your organization and your mailing address.

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* 5. Will you be paid by your organization to teach the fall prevention program or will you teach the program as a volunteer? If teaching as a volunteer, you will need to fill out OHSU volunteer paperwork before the training.

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* 6. Will you be teaching the class as a volunteer?

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* 7. Do you have a location in mind to teach the program or will you need assistance finding a location?

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* 8. Are you willing to coach the Matter of Balance Course at community locations that have requested the program?

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* 9. Certification requires participants  to  attend the entire training course. Do you agree to stay for the
entire course?

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* 10. Please check the following questions acknowledging your understanding of the program requirements.

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* 11. Thank you  for your interest in "A Matter of Balance Coach Training".  Once you have completed this survey please email matterofbalance@ohsu.edu to confirm registration. Please mail payment to: OHSU ThinkFirst Oregon, 3181 SW Sam Jackson Park Road, L-603, Portland, OR 97239  

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