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AMPLIFIED
ENROLLMENT
Welcome & Basic Info
First name
*
Last name
*
Email
*
Phone
City, State
*
Age
*
Amputation Journey
Are you an Amputee?
*
Yes
No
Type of Amputation
*
Above the Knee
Below the Knee
Arm/Hand
Other (Please Specify)
When did you become an Amputee?
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One word that best describes your journey so far
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Faith & Wellness
Would you describe yourself as faith-based/spiritual?
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Yes
No
Exploring
How has your faith shaped your healing journey?
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Do you have a favorite Scripture or encouraging quote?
*
Interests & Goals
Which areas interest you? (Select all that apply)
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Sisterhood & Support
Faith and Spiritual Growth
Healing & Wellness
Business & Entrepreneurship
Travel & Retreats
Public Speaking/Storytelling
Ministry/Service
Fashion & Beauty Empowerment
Other
What do you hope to gain from Amplified?
*
Would you be interested in mentoring, speaking, or leading?
*
Yes
No
Maybe
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