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* 1. Is anyone in your household a Wellcare member?

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* 2. Name:

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* 3. Phone Number:

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* 4. Address:

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* 5. County

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* 6. Email:

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* 7. Birthdate:

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* 8. Gender:

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* 9. Marital Status:

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* 10. Number of people in household?

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* 11. Number of people with income?

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* 12. Annual Household Income (all sources):

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* 13. How did you hear about the workshop?

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* 14. How did you hear about the workshop?

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* 15. What is your current housing status? (renting, family, etc.)

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* 16. Highest education level:

NOTE: The classroom setting will not be appropriate for children. Please make other arrangements for childcare before attending class.

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