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Enrollment Form
Child's First Name*
Child's Last Name*
Child's Birthday*
Male / Female*
Address*
School*
Grade as of September 1*
Teacher*
Mother / Guardian's name*
E-mail Address*
Complete Address: (Street), City, State, Zip Code)*
Daytime Phone Number*
Cell Phone Number:*
Father / Guardian's name:*
E-mail Address*
Complete Address: (Street, City State, Zip Code)*
Daytime Phone Number*
Cell Phone Number*
Please Indicate primary contact: *
Child's Medical Doctor:*
Doctor's Phone Number:*
Hospital Preference:*
Insurance Co. & Policy Number*
Please indicate your child's known allergies, medications, or special circumstances:*
Please Indicate Emergency contacts and person or persons authorized to pick up your child: Name / Phone Number / Relationship*


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