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* 1. Who is filling this form out?

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* 2. What program would you like to register in?

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* 3. Name of individual interested

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* 4. What are your pronouns?

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* 5. Date of Birth

Date

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* 6. Any dietary requirements?

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* 7. Do you require any supports to access this program?

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* 8. Is there any other information you wish to tell us or think that we should know? This may include past trauma or topics that may trigger some negative emotions. This will help our support persons support you best.

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* 9. Can you please specify what your disability is.

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* 10. Contact details

Thank you for registering. Following the completion of this registration, our team will get in touch with you. - SHIBUI Team

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