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  MOVEMENT 101 ONLINE APPLICATION  | Due December 21, 2007.
NAME:  
ORGANIZATION (IF ANY):  
HOME PHONE:  
CELL PHONE:  
ADDRESS
include city, state, zip and apt:		  
EMAIL:  
AGE:  
RACE/ETHNICITY:  
GENDER:  
CLASS:  
SEXUALITY:  
WHAT IS YOUR
POLITICAL BACKGROUND?		  
WHY DO YOU WANT TO PARTICIPATE IN MOV 101?  
WHAT IMPACT WILL MOV 101 HAVE ON YOUR WORK?  
WHAT SPECIFICALLY DO YOU WANT TO LEARN IN MOV 101?  
WHAT DAY/TIME CAN YOU ATTEND?
MONDAY 6 - 9PM  
TUESDAY 6 - 9PM  
WEDNESDAY 6 - 9PM  
THURSDAY 6 - 9PM  
SUNDAY 3 - 6PM  
WOULD YOU NEED?
CHILD CARE  
TRANSLATION  
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