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Required Required Question(s)
1.

Please enter the information indicated below.
(for 'home phone' please indicate the cell, home, etc. number you use most frequently)

By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
City:
State/Province
(US/Canada):
Postal Code:

Required 2.

Gender
Male
Female
3.

Birthday
 

  • 50 characters left.
Required 4.

Please order the EVENING times (from 1st to 4th choice) that you are available. Please note in the comments box the specific hours that you are available.


(1 = 1st Choice (I'm available!))
 
Sunday 7pm or after
Monday 7pm or after
Tuesday 7pm or after
Wednesday 7pm or after
Thursday 7pm or after
  • Comment:

  • 500 characters left.
5.

Group Preferences: Please check all that apply to you. We will try to accommodate you as best we can.
I prefer a group in my residence hall
I prefer a co-ed group
I prefer a single-sex group
I have no preference
Other  
  • Comment:

  • 500 characters left.