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RPSA Youth Firearm Violence Prevention Program
Do you live in Lake County?
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Last Name
Date of Birth
Telephone Number
E-mail Address
Age
Address
Apartment / Suite
City
State
Zip Code
Gender
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What city do you live in?
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North Chicago
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Ethnic/Racial Information
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What is your Primary Language?
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English
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Current Level of Education
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High School
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Are you currently in school or out of school?
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How did you hear about us?
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