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2. Your First and Last Name*
4. Your Address*
6. Your Phone Number*
8. Your Email Address*
10. Volunteer or Recipient
    -- Select One --VolunteerRecipient

    A volunteer is interested in helping a neighbor.

    A recipient is interested in receiving assistance due to a physical limitation or inability to pay.

12. Volunteers only: How far are you willing to travel?
    -- Select One --< 1 Mile1 - 2 Miles> 3 Miles
14. Additional Information
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16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

* indicates a required field