Virtual Health Fair Registration Form

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Virtual Health Fair Registration Form

Contact us at - HealthIsWealthRegion9@gmail.com
Outreach Chairperson - Karen Buchanan | kbuchanan2227@yahoo.com | 501-590-4471

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* Indicates required question

Student's Name (Last, First, MI) *

Your answer

What is your gender? *

Male

Female

Prefer not to say

Email Address *

Your answer

Home Address (City, State Zip) *

Your answer

Telephone Number (XXX-XXX-XXXX) *

Your answer

Age *

Your answer

Grade Level *

9th

10th

11th

12th

Race *

White

Black or African American

Hispanic, Latino or Spanish

Asian

Native Hawaiian or Other Pacific Islander

Other

School *

Your answer

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