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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 character(s) 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 character(s) 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 character(s) left.