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* 1. Name

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* 2. County of Residence

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* 3. Phone Number

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* 4. E-Mail

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* 5. Number of Children

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* 6. Current Grade Level of Children (Check All that Apply)

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* 7. Would you like to be actively involved in the efforts (work on a committee, host a meeting, distribute information, etc)?

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* 8. If answered yes above, how would you like to be involved?

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* 9. What is best way to contact you?

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* 10. How did you learn about The DREAM Academy? (check all that apply)

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