| Name:* |
(first and last) |
| Student ID#:* |
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| E-mail address:* |
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| Address:* |
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| City/state/zip:* |
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| Phone number:* |
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| Why are you interested in living in the Wellness House?* |
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| What does wellness mean to you?* |
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| How do you think you would benefit from participating in the community?* |
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I understand that if I am accepted to the Wellness House that I will be required to sign and adhere to a substance-free lifestyle pledge.* |
