EMDASPORT Sport Clinic Application
Please fill out this form to satisfy application for the EMDASPORT Clinics. Thank you so much for joining our efforts to liberate our black boys and support them in becoming healthier everyday.
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First Name *
Last Name *
Preferred Name (if applicable)
Address *
City *
State *
Zip Code *
Primary Phone Number *
Alternative Phone Number *
Primary Email Address *
Birthday *
MM
/
DD
/
YYYY
Occupation *
Gender *
Preferred Pronoun(s) *
Preferred Racial Identity/ Preferred Ethnic Identity (if applicable) *
Romantic Status *
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