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[* Required items]
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Section 1: Student
Information |
| No. |
Student's Name |
Date of
Birth (ages 3-5 only) |
Gender |
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1: |
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2: |
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3: |
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Do any of your children
have any existing medical condition that requires special
attention? If yes, please explain:
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Family Doctor: |
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Doctor Phone: |
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Doctor Address: |
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Doctor City: |
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Doctor State/Zip: |
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Section 2: Parent
Information |
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*
Father's Name: |
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*
Mother's Name: |
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Home Address: |
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City: |
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State/Zip: |
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Telephone (home): |
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(cell): |
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E-mail Address: |
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Comments/Feedback (if
any): |
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Additional Services needed: |
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*
Your name: |
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Current Date: |
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