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General Info
I am going to be a: *
First Name: *
Surname: *
System Generated:
Alternative Email:
NickName: *
Gender: *
Password: *
Confirm password: *
Your Headline that everyone will see
on the Ezomndeni Net beneath your photo:
Miscellaneous Info
Birthday Month: *
Birth Day: *
Birth Year: *
Date of birth: *
Postal Code:
Time Zone:
Other Information
The industry that I work or would love to work in
(check all that apply): *
Pick the three best days of the week for video conversations
or coming to the mentoring lab:
Net Buddies: Please choose the 3 best times after school or
on the weekend for your 30 minute video conversations: *
Video Mentors: Please choose the best time of the day
for your video conversations: *
Street Address: *
School Name: *
School Grade: *
1st Parent/Guardian Name: *
1st Parent/Guardian Surname: *
2nd Parent/Guardian Name:
2nd Parent/Guardian Surname:
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