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Dr. Hines Inc
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Couples
Thank you for taking the time and filling out this form. #newclients
Husband's Full Name*
Husband's Birth Date*
Husband's Cell*
Husband's Email*
Husband's Street Address*
Husband's City/ State/ Zip Code*
Husband's Occupation*
Husband's Emergency Contact*
Husband's Emergency Phone*
Wife's Full Name*
Wife's Birth Date*
Wife's Cell*
Wife's Email*
Wife's Street Address*
Wife's City/ State/ Zip Code*
Wife's Occupation*
Wife's Emergency Contact*
Wife's Emergency Phone*
Relationship Status*
Engaged
Married
Living together
Separated
Children Name's , Age & Gender*
Religion
Any other information we should be aware of?
What is your favorite sport?
If other, please specify
What do you want to achieve out of coaching?*
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