2018-2019 Reclaim Registration
Email address *
Student Information
Student First Name *
Your answer
Student Last Name *
Your answer
Gender *
Date of Birth *
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DD
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YYYY
School? *
Your answer
Is the student actively involved in a church? If so, what church? *
Your answer
Does the student have any known allergies? If so, what allergies? *
Your answer
Does the student take medicine regularly? If so, what medicine(s)? *
Your answer
Are there security issues for your child? If so, what security issues? *
Your answer
Please share if your child has any physical limitations or special concerns: (If you prefer to discuss these in person, please contact us.)
Your answer
Ethnicity
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