Libertyville Junior High Improv Ensemble
Grades 4th-7th

SUNDAY 3:00 - 4:30 pm

Student Name
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Grade (Fall)
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Parent/Guardian Contact 1
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Phone number (cell)
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Phone number (home)
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Phone number (work)
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Parent/Guardian (Contact 2)
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Phone number (cell)
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Phone number (home)
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Phone number (work)
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Student's Doctor's Name and Number
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Medical Conditions Staff should be aware of
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