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Child's Name *
Child's Name
Child's Date of Birth *
Child's Date of Birth
will be completed by June 11, 2018
Address *
Address
Parent/Guardian Name *
Parent/Guardian Name
Parent/Guardian Phone *
Parent/Guardian Phone
If none, please put 'none'
In Case of Emergency, Contact *
In Case of Emergency, Contact
Different than listed above as Parent/Guardian
Emergency Contact Phone *
Emergency Contact Phone