Free Laptop Application - Re*Imagine Medical Lake

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Name*

Phone

Email*

Why do you need a laptop? How will the laptop be used?*

Were you impacted by the Gray Road Fire?*

Yes

How were you impacted by the Gray Road Fire?*

Which address was impacted?*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you currently reside at this address?*

Yes

Current Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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