Kalakaua Clinic Waitlist Sign Up
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Father (Full Name) *
Your answer
Mother (Full Name) *
Your answer
Primary Contact (Full Name) *
Your answer
Primary Contact Email *
Your answer
Primary Contact Cell Phone *
Your answer
Other Phone
Your answer
Student (Full Name) *
Your answer
Grade *
Current School *
Your answer
Gender
Birth Date
Please make sure to specify birth year. Do not use the current year (2018).
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Age of Student *
Minimum age of acceptance is 7.
Updated email? (* Do not check for new registrations)
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