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Your first name
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Your answer
Your last name
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Your answer
Best email address for follow-up?
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Your answer
Where are you located?
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USA
Latvia
Other:
If in the US, which state?
Your answer
Full name of the youth you feel could benefit from Lighthouse's program?
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Your answer
What is your relationship to this youth?
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Your answer
How frequently do you speak with this youth?
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Every Week
1
2
3
4
5
A few times a year
Are you able or willing to provide scholarship funds for their program should they choose to participate?
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Yes
No
Maybe
Tell us a little bit about this young adult and their situation?
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Your answer
In your opinion, how likely is it that this young adult would show up for a consultation or event?
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Not likely at all
1
2
3
4
5
Very Likely
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