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* 1. In which of the following services would you have an interest?

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* 2. In your own words, identify the three most urgent needs in your neighborhood.

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* 3. If the service and activities you indicated were offered in your neighborhood, would you participate?

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* 4. Please indicate any area you would be interested in helping to provide:

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* 5. Please indicate any additional area you would be interested in helping to provide:

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* 6. Name and Contact Information (Optional - May apply N/A)