| ○ BROTHER | ◦ GRANDFATHER |
| ○ SISTER | ◦ UNCLE |
| ○ FATHER | ◦ AUNT |
| ○ STEPFATHER | ◦ COUSIN |
| ○ MOTHER | ◦ FRIEND/SCHOOLMATE |
| ○ STEPMOTHER | ◦ OTHER: SPECIFY: ________________ |
| ○ GRANDFATHER |
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