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* 1. Are you a resident of the City of Coconut Creek?

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* 2. Which category/categories below includes your age or participant with Special Needs?

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* 3. Please tell us if you or anyone in your household has been diagnosed with any of the following special needs. (Please check all that apply)

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* 4. Would you or anyone in your household be interested in participating in any of the following special needs activities? (Please check all that apply)

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* 5. What day of the week works best to participate in an activity you are interested in? (Please check all that apply)

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* 6. What time of the day works best for you to participate in the activity? (Please check all that apply)

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* 7. If you are interested in special needs activities, please provide your name, phone number and/or email. Call Angela Alvarez, Recreation Programmer, at the Community Center 954-545-6670 for further information or email aalvarez@coconutcreek.net .

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