| *Participant's First Name: |
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| *Participant's Last Name: |
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| *Parent/Guardian Name: |
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| *Address: |
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| *City: |
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| *State: |
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| *Zip: |
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Primary Phone:
(555-555-5555) |
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Work Phone:
(555-555-5555) |
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*Cell Phone:
(555-555-5555) |
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| *Email: |
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*Birthday:
(MM/DD/YYYY) |
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| *Last Grade Completed: |
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| Are you a member of this church? |
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Church:
(If not, where do you attend?) |
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VIP:
(Special Needs Program Includes (Autism; ADHD; Down Syndrome; etc.) |
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Allergies, Medical, & Special Needs:
(Leave Blank if None) |
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| *Emergency Contact Name (1): |
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*Emergency Contact Phone (1):
(555-555-5555) |
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| Emergency Contact Name (2): |
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Emergency Contact Phone (2):
(555-555-5555) |
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| *Authorized Pickup #1: |
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| Authorized Pickup #2: |
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Southfork:
(Riding the Southfork Bus?) |
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| May we have permission to photograph your child? |
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| May we have permission to use your child's photograph in church publications? |
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| Comments: |
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| Gender: |
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| *Choose the days that your child will attend: |
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