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Healing Reins Participant Application

Participant Information
Please be as thorough with your answers as possible. The more we understand about you, the better we can serve you! All information is protected by our confidentiality policy.
Participant Name *
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Date of Birth *
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Age *
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Diagnosis: Primary *
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Diagnosis: Secondary
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Gender *
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Height *
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Weight *
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Primary Phone (please tell us if it is cell or home ) *
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Email Address
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Street Address *
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City *
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Zip Code *
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School/Institution/Employer Name
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Is the Participant a *
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