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"A New Year - A New You" Registration

Please complete the form below. Required fields marked with an asterisk *

Contact Information

First Name*

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Last Name*

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What is your TEAM name?*

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Please indicate your team members, their contact phone numbers, Email addresses & a T-shirt size for each. (Must have 5 members for a team). Please indicate if you wish to participate as an individual.*

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Home Phone*

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Mobile Phone

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Work Phone

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Yes

Confirmation Email

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