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Where To Start Juicing/Fasting 
We're so excited to have you join us for our Where To Start Juicing/Fasting Course!! September 19th, 6:30pm - 8:00 @ Y.O.U.T.H Center.


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First Name *
Last Name *
Gender *
D.O.B. *
Occupation/School *
What is your Nationality/National Identity? *
If you put other, please indicate your Nationality below.
Please share any Social Media handles that you would like for us to have.
Email *
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Please fill in any dietary restrictions. If none, answer NONE. *
Do you own a juicer? *
If you answered yes. How often do you use your juicer?
PHOTO/VIDEO RELEASE AGREEMENT  By participating in programming of The BIPOC Rise Moor Healing Center, I, the undersigned Participant, irrevocably grant The BIPOC Rise Moor Healing Center, its representatives, and assigns, the unrestricted right to capture and use my image, likeness, voice, and performance in photographs, videos, and other media ("Media") for any lawful purpose, including promotion, education, and public relations, without compensation. I understand that all Media captured during all programming will be the sole property of The BIPOC Rise Moor Healing Center. I hereby release The BIPOC Rise Moor Healing Center and its affiliates from any claims, including those for libel or invasion of privacy, arising from the use of my Media. I affirm I am of legal age or have parental consent.  If you agree input yes and if you disagree input no. If you are filling this out and are underage, your parent/guardian/caregiver will be given a separate form  to fill out.
By answering no, does not disqualify you from participation. *
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