2021-22 Taubah Academy Registration Form
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PARENT'S INFORMATION
Parent's First Name *
Parent's Last Name *
E-mail *
Home Address *
City *
County *
State *
Zip Code *
Primary Phone *
Secondary Phone
1ST STUDENT'S INFORMATION
1st Student's First Name *
1 st Student's Last Name *
Date of Birth *
Grade Level *
Current / Most Recent School Name *
2ND STUDENT'S INFORMATION
2nd Student's First Name
2nd Student's Last Name
Date of Birth
Grade Level
Current / Most Recent School Name
3rd STUDENT'S INFORMATION
3rd Student's First Name
3rd Student's Last Name
Date of Birth
Grade Level
Current / Most Recent School Name
EMERGENCY CONTACT (E.C.)
Name and Phone 1 *
Name and Phone 2
MEDICAL INFORMATION
Any known allergies?
.
Yes
No
Please, all know allergies, if any!
Family Phisician's Name
Phisician's Phone
TERMS OF APPLICATION *
Required
Submit
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