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* 1. First Name

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* 2. Last Name

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* 3. Email

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* 4. JDRF Chapter (if you do not know your JDRF Chapter, please say "I don't know")

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* 5. City

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* 6. State

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* 7. Zip Code

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* 8. Phone

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* 9. Package

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* 10. Have you participated in a JDRF Ride in the past?

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