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WVCC Intake Form
How did you hear about today's event?
If other
Disabled Condition
Are you currently employed?
Have you ever served in the military?
If yes, are you disabled?
If other
Do you know how to ride a bike?
How many live in your household, including yourself?
Have your utilities (gas, electric and/or water) been shut off in the past 12 months?
Do you have dental, medical or mental health need?
Other Commentsmore details
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