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Child's First Name (Required)

Child's Last Name (Required)

Child's Gender (Required)

Child's Age (Required)

Child's Date of Birth (Required)

Child's Home Address (Required)

Phone Number (Required)

Parent Email (Required)

Father's Name (Required)

Father's Address (if different from child's) (Required)

Father's Occupation and Work Adress (Required)

Father's Work Phone (Required)

Mother's Name (Required)

Mother's Address (if different from child) (Required)

Mother's Occupation and Work Address (Required)

Mother's Work Phone (Required)

Child's Living Arrangement (Mom, Dad, Both) (Required)

Child's Legal Guardian (Mom, Dad, Both) (Required)

My child can be released to the following: (name, phone number, address) (Required)

Emergency Contact (Name, Phone Number) (Required)

Child's Doctor Information: (Name, Phone Number) (Required)

My child has the following special needs or accommodations needed: (Required)

My child is on the following long term medications (Required)