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WMAA Registration Form
April 16-19, 2018
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IN ORDER TO ENSURE THAT OUR PROGRAMS ARE EQUITABLE AND INCLUSIVE, WE WOULD LIKE TO ENLIST YOUR COLLABORATION BY RESPONDING TO A FEW QUESTIONS ABOUT YOURSELF.  YOUR ANSWERS WILL HELP US EVALUATE OUR SERVICES THROUGH THE LENS OF EQUITY AND INCLUSION.  AND, PLEASE DON'T HESITATE TO REACH OUT TO US SHOULD YOU HAVE ANY QUESTIONS ABOUT THIS PRACTICE.
NAME *
ORGANIZATION *
SECTOR *
TITLE/POSITION *
CONTACT NUMBER *
EMAIL *
RACE *
ETHNICITY *
GENDER/GENDER IDENTITY *
SEXUAL ORIENTATION *
DISABILITY *
PLEASE INDICATE ANY DIETARY NEEDS
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