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About-Face Presentations - Request Form

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I. Basic Information

First Name (required)
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Last Name (required)
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E-mail Address (required)
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Street Address (required)
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City (required)
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State (required)
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Zip (required)
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Country (required)
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Phone Number (required)
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School/Organization (required)
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Desired presentation date (mm/dd/yyyy format, please)
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II. Presentation Information

Reason for a presentation (fits into class curriculum, body image issues arising in individuals)
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Anything specific you would like to see addressed in this presentation?
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How did you hear of these presentations?
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III. Participant Information

How many anticipated to attend? (number only)
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Age range (numbers, dashes and spaces only)
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Gender
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'; } ?> > Male     > Female     > Both

Race/Ethnicity
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How familiar are the participants with the content matter?
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'; } ?> > They don't have a clue.
> They have some idea, but it's mostly rumor.
> They're half in-the-know, but there's room for improvement.
> They're pretty well informed, but they can learn something new.
> They know it like the back of their hand, and we want to cheer you on.

Anything else you would like to share about the participants?
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