Children's Campaign - Share Your Stories Survey

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1.	What is your First Name?*

2.	What is your Last Name?*

3.	Can we publish your story on our website?*
	Yes, I would like my story published.
	No, I would like my story to remain private.

4.	What is your E-mail address?* Your email address will remain private and will NOT be published.

5.	Where do you live in Florida?* Please enter your City.

6.	Share your stories, comments, and thoughts below.

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