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Splash Week 2015
Cost:
SRC Members: $85
Non Affiliated Members: $110
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Participant Information
Name
(Last, First)
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Date of Birth
(Last, First)
MM
/
DD
/
YYYY
Sessions
Session 1 June 15 - 19
Session 2 August 3 - 7
Parent/Guardian Information
Name
*
(Last, First)
Your answer
Jag Number
Your answer
Adress
(Street, City, State, Zip)
Your answer
Phone Number
*
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Email
*
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Emergency Contact Information
Name
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Relationship
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Phone Number
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Medical Information
Does the participant have any medical condition of which the instructor should be aware?
Yes
No
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