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Email address
confirm email
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Child's First Name
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Child's Last Name
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Child's Date of Birth (mm/dd/yy)
MM
/
DD
/
YYYY
Second child name & date of birth (d/m/y)
MM
/
DD
/
YYYY
Parent / Caregiver First Name
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Parent / Caregiver Last Name
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Street address
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City
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home phone
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cell phone
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alternate phone (work? other cell?)
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