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Woman Within® Online Skills Workshop 2020
Staff Registration Form, South Central
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Woman Within welcomes all women and prohibits discrimination based on race, colour, gender, national origin, age, religion, disability, sexual orientation and gender identity.
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First Name
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Last Name
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Contact details:
Email
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Primary phone
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Other phone
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Address
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City
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State/Province
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Zip or Postal Code
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Country
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Date of birth
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Please remember to change the year to your birth year
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Date and place I attended my own Woman Within® Weekend:
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By signing this form, indicates full understanding and acceptance of the information, terms and conditions outlined on this form.
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By printing my full name below, I agree that all information provided in this form is true and correct. Writing your name constitutes an electronic signature which is legally binding and has the same legal status as handwritten signatures throughout the United States, under the ESIGN Act and the Uniform Electronic Transactions Act (UETA).
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