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* 1. Name (First and Last):

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* 2. Title:

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* 3. Email:

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* 4. Program or Site Name:

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* 5. What days best accommodate your participation in the workgroup?

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* 6. What time of day best accommodates your participation in the workgroup?

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* 7. What areas/topics would you be interested in working on or hearing about during workgroup sessions? (Check all that apply)

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* 8. Do you have any suggestions or specific ideas for activities for the workgroup?

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* 9. Would you like to invite any other members to join the workgroup? (Add their name and email below)