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* 1. Name

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* 2. Email

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* 3. Please select your gender 

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* 4. Please select your race 

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* 5. If you self-identify as American Indian/Alaskan Native, what is your Tribal Affiliation?

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* 6. Would you like to receive updates from the Urban Indian Coalition of Arizona?

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* 7. Please upload your image here (i.e. upload photo of loved one, you walking, resources, etc.)

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* 8. #AMileFor… share why you're participating:

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* 9. Do you consent to the Urban Indian Coalition of Arizona to share your story on Instagram, Facebook, or Twitter?

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* 10. If yes to question 9, would you like us to share your story anonymously?

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* 11. Are you unable to participate due to a disability?

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