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

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Select Shoe Size

Please check the boxes that apply to you.
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?
Do you have any fears or concerns that may affect your participation in this program?

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

How did you hear about this program?

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