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Name of administrator filling out this form
Date
Primary email for contact:
Primary country for this group affiliate
Countries represented in your current student groups:
Number of students currently enrolled in GoLife100
Number of students currently enrolled in GoLife200
Number of students currently enrolled in GoBus100
Number of students currently enrolled in GoBus200
Number of students currently enrolled in GoCitizen
Number of facilitators currently leading a GoLife Group
Number of facilitators currently leading a GoBusiness Group
Number of facilitators currently leading a GoCitizen Group
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If your groups participate in multiple languages, please indicate number of students in each language group: