1.   Are you interested in joining this group? (R)

        Yes
        No

2.   Please provide your full name. (R)

     

3.   What is your WDC handle/user name?
*Please be sure this is always updated with the group owner*
~*~Damiana Renewed~*~ (R)

     

4.   Please provide you date of birth.
*This information is confidential and required for classification purposes only* (R)

     

5.   Do you certify that you are 18 years of age or older? (R)

      Check this box to agree with the above statement.

6.   Please Select your gender. (R)

        Male
        Female

7.   What is your WDC email address? (R)

     

8.   Please select your highest grade level completed. (R)

        Grade 7 or under
        Grade 8-10
        Grade 12

9.   What do you feel are your strenghts? example: reading, math etc. (R)

     

10.   Where do you need the most help? (R)

     

11.   Where did you find this group? (R)

     

12.   Were you referred by another member? If yes, who? (R)

     

13.   I agree to conduct myself in a mature and respectful manner to everyone at all times. If at any time I experience difficulty with another member of this group; I agree to bring it to the attention of Damiana and not handle it myself. I realize that this group is for my benefit and that priviledge can be revoked at any time. (R)

      Check this box to agree with the above statement.

14.   This survey allows the sending of Gift Points.
      Gift points aren't required but always welcome. They are NOT dependant on your acceptance to this group.

      You currently have 0 Gift Points.
      Enter the number of Gift Points to be sent:
      Confirm this Gift Point amount by re-entering:
      (From a minimum of 100 to a maximum 250,000 Gift Points.)

Important: Gift Points included will be sent to ~*~Damiana Renewed~*~ . Writing.Com will deduct a fee of 2.5% for processing the transaction for member. Gift Points sent through this form are not refundable for any reason. Please use good judgement when sending Gift Points to any member or group.

Disclaimer: The information that you are submitting with this survey form is being sent to ~*~Damiana Renewed~*~ . It is NOT being sent to Writing.Com. You should be careful to not submit any information which you may deem as private or confidential. Writing.Com and its affiliates will not and may not be held responsible or liable, in any way, for any damages that may or may not arise from your submission of this form.