PLEASE COMPLETE ALL FIELDS - ALL INFORMATION WILL BE KEPT PRIVATE AND CONFIDENTIAL
Email address *
FIRST NAME *
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LAST NAME *
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PHONE NUMBER *
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DO YOU WISH TO: *
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YOUR NEAREST LOCATION/SECTOR *
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ADDRESS OR DESCRIPTION OF HOUSE AND LOCATION *
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TOTAL NUMBER OF PERSONS IN YOUR HOUSEHOLD *
HOW MANY ADULTS AND CHILDREN LIVE IN YOUR HOUSE?
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IF THERE ARE CHILDREN, HOW MANY AND WHAT ARE THIER AGES? *
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IF THERE ARE ELDERLY PERSONS, HOW MANY AND WHAT ARE THIER AGES? *
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DOES ANYONE IN THE HOUSEHOLD HAVE SPECIAL NEEDS? IF YES, BRIEFLY DESCRIBE: *
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WHAT ARE YOU IN NEED OF? *
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BY REGISTERING WITH VIEQUES READY, I AGREE TO INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE THE ENTITIES OR PERSONS REPRESENTING THE ORGANIZATION FROM ANY AND ALL LIABILITIES OR CLAIMS MADE AS A RESULT OF PARTICIPATION IN THIS SERVICE, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASE OR OTHERWISE. *
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