Which family member(s) are you referring to? What is the relationship between your current student(s) and the heart beat student's referred student (please provide details)? Have you ever had any heart beat events at any time from any cause? What were, and how frequently did heart beats take place? Name of person(s) who helped you apply for or volunteer at Heartbeat. Name of organization(s) your relationship with. Please list in the same order as listed above. If you do not yet know which organization(s) your relationship is with, please provide information for each of your relationships as below. What type of events did your current student(s), referred student(s), or organization(s) participate in which may be attributed to Heartbeat? Have you, or anyone in your family, ever been to Heartbeat before and, where applicable for a heart beat school, what did you do at Heartbeat that you believe was important to you as a person to be proud of? If so, what makes your Heartbeat experience significant to you? What was, or is, your experience with Heartbeat? How is Heartbeat different from your experience? What are some things that Heartbeat students are able or not able to do, or have not yet tried to do, that you find helpful? Name of someone (or organization(s)) for whom you will be volunteering or applying for school. If you are applying for school please provide a contact number and/or e-mail address. Name of organization (s) to which you would like to be a sponsor; name of person, company, etc. to whom you will offer help; how you hope to show support for Heartbeat (e.g., volunteer at Heartbeat, assist Heartbeat students, provide other support, etc.); if you are a parent of a heart beat student who is applying for school, please indicate in your profile if your child is currently a Heartbeat student. Name(s) of people (including the organization(s)) with whom you have had a relationship that provides valuable support. Name(s) of organizations (including your organization(s)) with which you, or they are working, with links to your organization(s) which contain information about Heartbeat. How can we best connect you with people from your area of interest, or with people who have had their hearts broken through heart beat events (e.g.
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HEARTBEAT STUDIOS STUDENT REFERRAL PROGRAM September 2006 to June 2007 Name of Referred Student: Address of Referred Student: Phone of Referred Student: Date Enrolled: Classes Referred Student Enrolled
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