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Title
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If you answered OTHER to the question above, please specify your answer here:
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First Name
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Last Name
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Email Address
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Phone
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Address
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City
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State/Province
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Zip Code
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Gender
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If you answered OTHER to the question above, please specify your answer here:
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Race/Ethnicity (Select all that apply)
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If you answered OTHER to the question above, please specify your answer here:
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Age
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How did you hear about this event? (Please select all that apply.)
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If you answered OTHER to the question above, please specify your answer here:
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Is this your first time attending Take Heart?
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Are you a heart family or health care professional?
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If you answered OTHER to the question above, please specify your answer here:
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If you are a healthcare professional, please specify which field you work in: (please leave blank if you are not a healthcare professional)
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If you answered OTHER to the question above, please specify your answer here:
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Company, Hospital or Organization Affiliation (Please leave blank if you are not a healthcare professional.)
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Are there others that live in your household? (Please leave blank if you are not a heart family.)
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How many people live in your household (including you)? (Please leave blank if you are not a heart family.)
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What is your heart warrior’s name? (If multiple please separate names with a comma. Please leave blank if you are not a heart family.)
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How old is your heart warrior? (Please leave blank if you are not a heart family.)
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My heart warrior is deceased. (Please leave blank if you are not a heart family.)
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What hospital did (or does) your heart warrior receive treatment? (Please leave blank if you are not a heart family.)
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What is your heart warrior’s primary cardiac diagnosis? (Please leave blank if you are not a heart family.)
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Would you like to receive an OHHF t-shirt for your heart warrior and/or their siblings? *T-shirts available while supplies last. (Please leave blank if you are not a heart family.)
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If you answered yes above, how many shirts? (Please leave blank if you are not a heart family.)
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Please select your child’s t-shirt size: (Please leave blank if you are not a heart family.)
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If you need multiple shirts, please specify size and quantity below: (ex. 2 Youth M, 1 Adult L), (Please leave blank if you are not a heart family.)
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Are you interested in receiving more information about free mental health services for heart families through Ollie’s Branch?
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Comments or questions?
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