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Sports Clinic Registration
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Untitled Title
Name James Bermudez
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Grade 10th
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Address
137 Canterbury rd
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Town/City
Springfield
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State
Ma
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Zip Code
01118
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Phone Number
413 3062958
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T-Shirt Size
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Insurance Carrier
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Insurance Policy Number
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Allergies/Medical Conditions
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I hereby state that my child is in good health. In the event of an emergency, I give permission to the PFSJCS/SECC staff to treat my child. I waive all liability toward PFSJCS and SECC. (Parent/guardian signature)
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Paulo Freire Social Justice Charter School marketing staff may take pictures of your child to use in future promotions. Your signature below gives PFSJCS permission to use your child's picture in future promotions/social media/commercials.