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Child Information
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* Indicates required question
Today's Date
*
MM
/
DD
/
YYYY
Child Name
*
Your answer
Birthdate
*
MM
/
DD
/
YYYY
Current Age
*
Your answer
Current Grade (if applicable)
Choose
Pre-K
K
1
2
3
4
5
Parent/Guardian Name(s)
*
Your answer
Phone
*
Your answer
Alternate Phone
*
Your answer
Email Address
Your answer
Home Address
*
Your answer
Mailing Address (if different)
Your answer
Who is authorized to pick up your child? Please list name and relationship to your child.
*
Your answer
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