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Email
*
Your email
First Name (this is the name you would like us to call you. It does not have to be your legal name.)
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Your answer
Last Name
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Your answer
Phone/Texting Number
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Your answer
Home Address #1 (we will only use this information in case of an emergency where we need to send someone to check on you at home. We will ask permission before mailing anything to your home)
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Your answer
Home Address #2
Your answer
City
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Your answer
State
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Your answer
Zip Code
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Your answer
What school are you currently attending?
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Your answer
Name of Emergency Contact Person (Must be an adult 18+)
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Your answer
Emergency Contact Phone Number
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Your answer
Emergency Contact Relationship To You (your parent, aunt, sibling, etc)
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Your answer
Are you out to your Emergency Contact?
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Yes
No
Do we have you permission to use the name you gave us with your Emergency Contact?
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Yes
No
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