PINK OUT Zumba Class - Oct. 9th
Thank you for registering for this event! We can't wait to see you there. After you complete this registration form, we will send email reminders of the class as we lead up to it.

If you have any questions or concerns, please contact Gillian Smith at gsmith@cbww.org. 
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Email *
Full Name *
What is the best phone number to reach you? *
Please provide your mailing address with zip code (We won't be mailing you anything. This information is for grant reporting purposes only). *
What is your gender? *
What ONE race do you identify with most? *
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What is your ethnicity?
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Have you been a CBWW client, patient, or participant before? Please select all that apply. *
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What age group do you belong to? 
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If you do NOT have insurance, are you interested in receiving low-cost clinic services at CBWW? 
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How did you hear about this event? *
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Are you without health insurance and are interested in receiving a FREE clinical breast exam? This means a nurse at CBWW will examine your breasts for irregularities or signs of breast cancer. 
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Have you recently had a breast exam within the past year or are you scheduled to have one soon? *
Optional: Are you a breast and/or cervical cancer survivor?
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Optional:  Do you have a family history of breast and/or cervical cancer?
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