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WHAT IS YOUR RACE/ETHNICITY? (check one or more) Asian Indian Laotian Asian Other Hawaiian Central American Chinese Cambodia Black or African American Samoan South American Japanese Vietnamese American Indian/Alaskan Native Pacific Islander Other Hispanic Other Korean Filipino Guamanian White Mexican, Mexican American, Chicano 15. Would you like information regarding services for the following disabilities? (mark all that apply): Hearing Learning Speech Mobility or Ort.

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