Keshet YOUTH IAR (Information, Agreement & Releases)- Summer Community Students 2020
Please fill out the following information & click "Submit". If you have any questions or issues please contact us at frontdesk@keshetarts.org.
Today's Date: *
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Student First Name *
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Student Middle Name
Your answer
Student Last Name *
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Student Preferred Name or Nickname
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Student Date of Birth *
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Gender *
Student Address Street *
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Student Address City *
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Student Address State *
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Student Address Zip Code *
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Student Phone Number (with area code) *
Your answer
Student Email Address *
Your answer
Please identify any physical disabilities, restrictions, conditions, or illnesses which might require medical attention, impact student participation in classes, or be useful for instructor(s) to bear in mind: *
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Parent/Guardian 1 First Name *
Your answer
Parent/Guardian 1 Middle Name
Your answer
Parent/Guardian 1 Last Name *
Your answer
Parent/Guardian 1 Date of Birth
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Parent/Guardian 1 Gender
Parent/Guardian 1 Address Street *
Your answer
Parent/Guardian 1 Address City *
Your answer
Parent/Guardian 1 Address State *
Your answer
Parent/Guardian 1 Address Zip Code *
Your answer
Parent/Guardian 1 Phone Number (with area code) *
Your answer
Parent/Guardian 1 Email Address *
Your answer
Parent/Guardian 1 Employer (No acronyms please)
Your answer
Parent/Guardian 1 Relationship to Student *
Parent/Guardian 2 First Name
Your answer
Parent/Guardian 2 Middle Name
Your answer
Parent/Guardian 2 Last Name
Your answer
Parent/Guardian 2 Date of Birth
MM
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DD
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YYYY
Parent/Guardian 2 Gender
Parent/Guardian 2 Address Street
Your answer
Parent/Guardian 2 Address City
Your answer
Parent/Guardian 2 Address State
Your answer
Parent/Guardian 2 Address Zip Code
Your answer
Parent/Guardian 2 Phone Number (with area code)
Your answer
Parent/Guardian 2 Email Address
Your answer
Parent/Guardian 2 Employer (No acronyms please)
Your answer
Parent/Guardian 2 Relationship to Student
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