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Please check all that apply. African-American Native American Asian/Pacific Islander Hispanic White non-Hispanic Other specify 4. From mo. /year To mo. /year Approximate hours/ week OR total hours 3. Ethnic racial or cultural diversity of children or youth that candidate worked with. 11/1/2016 SMK Optional record of hours worked or volunteered Use only for tracking current hours. Past hours use 2 on reverse DATE OR DATES Total hours worked or volunteered HOURS NOTES Minimum application...

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