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Name
Organization Name
Organization Address
Telephone
Email
How would you identify yourself? Please check all that apply:
Faith based organization
Community Member
Physician
Treatment Counselor
Nursing
AHEC Staff
LGBTQIA+ Organization
Student (Undergraduate)
Student (Higher Ed.)
Non Profit Institution
Treatment Facility
Allied Health
Dentistry
Other (please list)
Are you interested in serving on the Volunteer Community Advisory Board?
Yes
Maybe
No
Would you be willing to complete quarterly surveys that help us better understand programmatic application of community needs in student academics?
Yes
Maybe
No
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