Jumping into KG and Learning in Motion PreK
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Student's First Name *
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Student's Last Name *
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Date of Birth *
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Parent / Guardian First Name *
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Parent / Guardian Last Name *
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Street Address *
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City *
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Zip *
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Home Phone Number *
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Primary Parent / Guardian Work Phone No. *
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Secondary's Work Phone No. *
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Primary Parent / Guardian Cell Phone No. *
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Secondary's Cell Phone No. *
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Emergency Contact Name *
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Emergency Contact Phone No. *
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Permission for my child to receive emergency medical care and be transported to a medical facility if my child's guardian or I cannot be reached *
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Any special health conditions we should be aware of? (e.g. bee sting allergies, peanut allergies, medications). *
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