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Self-care Support Kit Sign-up
Sign-up for our Self-care Support Kit for the opportunity to receive a free self-care kit!
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* Indicates required question
Email
*
Your email
Name (First and Last)
*
Your answer
Where are you located? (City and State)
*
Your answer
What's your birthday (month and day only)
*
Your answer
How long you have been a Caregiver?
*
1 - 3 years
3-5 years
5-10 years
Over 10 years
Who do you care for?
*
Elderly parents
Grandparents
Great-Grandparents
Aunt or Uncle
Older Sibling
Spouse
How often do you make time for self-care?
*
Once a week
Twice a week
Daily
Once a month
Rarely
What are some of your favorite self-care activities?
*
Your answer
What are some of your favorite self-care items to use?
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Your answer
Which of these grocery stores are in your area
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Walmart
FoodLion
Kroger
Harris Teeter
Which Movie Theaters are in your area
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Cinema Cafe
AMC
Regal
What is your favorite color?
*
Your answer
What is your T-shirt and Hoodie Size?
*
Your answer
List 3 of your favorite Stores
*
Your answer
List 3 of your favorite restaurants
*
Your answer
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