LUMINA Center Event Registration
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Email *
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Name: *
Activity/Event/Class: *
Address: *
Phone Number: *
Email: *
Birthdate: *
MM
/
DD
/
YYYY
Grade: *
Male or Female: *
Do you have an access card?
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Race:
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School: *
Parent's Signature and Date *
Emergency Contact and Phone Number *
Submit
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