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PARTICIPANT REGISTRATION
PARTICIPANT REGISTRATION

PARTICIPANT REGISTRATION

First Name*

Last Name*

Company

Address*


City*

State*
Postal Code*

Country*
Email*

Day Phone*

Evening Phone

Please select Activity.  Activities below are held in Broward County, Florida.
Birthdate

Birthdate

Input Birthdate:  Month Day, Year (ex. April 4, 1994)

Select Shirt Size

Select Shirt Size

Select Shoe Size

Select Shoe Size

Please check the boxes that apply to you.
Details of Eligibility

Details of Eligibility

Please provide details of your disability or other special needs...  For example, if you have a physical impairment, are you mobile or confined to a wheelchair?  If you selected 'Other Special Needs Group', please describe.

Was the cause of your impairment service related?
Issues/Concerns

Issues/Concerns

Do you have any fears or concerns that may affect your participation in this program?

Expectations

Expectations

What do you expect to gain from participating in this program?

Referring Source

Referring Source

How did you hear about this program?

Verifier

Verifier

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