*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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*Cell Phone: (555-555-5555) |
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*Email: |
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*Birthday: (MM/DD/YYYY) |
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*Current Grade: |
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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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Do you attend Church? |
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If so, where? |
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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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How did you hear about PNO?: |
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*Choose the days that your child will attend: |
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