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2. First Name*
3. Last Name*
5. Address*
7. City
8. State
9. Zip Code
11. Email Address
13. Phone Number
15. Name of Program*
16. Do you have an existing following?*
    -- Select One --YesNo
18. Description of Program*

    This will serve as an overview of your program

20. Proposed Date (s), Time(s), and Location*
22. Min-Max number of participants*
23. Age Range*
24. Lesson Plan
26. Proposed cost per participant*
27. W9*
28. Proof of Commerical Liability Insurance *
29. Marketing Material
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31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field