Please list the Name, Date of Birth & Gender of each child
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Child 1
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First Name:
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Birthdate:
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Gender:
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Child 2
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First Name:
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Birthdate:
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Gender:
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Child 3
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First Name:
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Birthdate:
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Gender:
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Child 4
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First Name:
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Birthdate:
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Gender:
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Child 5
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First Name:
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Birthdate:
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Gender:
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Child 6
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First Name:
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Birthdate:
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Gender:
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Work Phone:
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Fax:
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Job Function:
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Job Title:
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Are you self-employed?
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Do you own a home-based business?
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Company Name:
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How many employees work at your location?
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What is your employment status?
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Industry:
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Work Address:
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Work City:
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Work State:
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Work Zip:
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Interests and Hobbies |
Party Affiliation:
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Do you own any of the following electronic devices? (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)
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Do you use any of the following smoking products? (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)
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Do you use streaming services?
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Internet Provider:
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Do you own a webcam?
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Vehicle Manufacturer
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Vehicle Year:
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Primary Vehicle Type:
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Do you own any of the following recreational vehicles (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)
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What is the make of your primary cell phone?
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What is your cellular service provider for your primary cell phone?
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What mobile operating system do you use on your primary cell phone?
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What of the following stores do you shop at?
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Medical Health |
Have you been diagnosed by a medical professional with any of the following conditions? (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)
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Have you been prescribed any medication by a medical professional (Specify which; Hold the <ctrl> key down to select/unselect multiple
responses)
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Do you have health insurance? (Specify which; Hold the <ctrl> key down to select/unselect multiple
responses)
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Are you, or is anyone in your household on any of the following diets? (Specify which; Hold the <ctrl> key down to select/unselect multiple
responses)
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Has anyone in your household been diagnosed by a medical professional with any of the following conditions? (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)
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Are you a caregiver for anyone diagnosed by a medical professional with any of the following conditions? (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)
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THANK YOU!
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