*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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Allergies, Medical, & Special Needs: (Leave Blank if None) |
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*Emergency Contact Name (1): |
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Emergency Contact Name (2): |
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*Authorized Pickup #1: |
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Authorized Pickup #2: |
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*Choose the days that your child will attend: |
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