Crimson Charities - Student Application
6125 W. National Avenue
West Allis, WI 53214
(414) 206-2521
Student First Name *
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Student Last Name *
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Student Date of Birth *
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Student Cell Phone (optional)
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Home Address *
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City *
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State *
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Zip Code *
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School *
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Entering Grade *
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Program Interest:
What is your Parent/Guardian's Home Phone Number?
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What is your Parent/Guardian's Cell Phone?
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What is your Parent/Guardian's Email?
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Emergency contact person 1 & phone #? *
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Emergency contact person 2 & phone #? *
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Emergency contact person 3 & phone #?
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List any medical conditions or allergies. Put n/a if this does not apply. *
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