Please fill in the non-binding form below.

Note that your registration will not be complete until you have spoken with someone in the Choices office.

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Registration

Name*
Birthdate
MM slash DD slash YYYY
Email*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone*
Home Phone
Marital Status
Gender
- Male
- Female
Employer/Occupation
Are you a smoker?
- Yes
- No
Referred By*
Which seminars are of interest to you?
- Choices
- Givers I\II
- Super Choices/Super Givers
- Teen/Family Camp
Choose a location*
Which month do you plan to attend?
Additional Comments
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