BEHC 2018-2019 REGISTRATION
2018-2019
Student First Name *
Your answer
Student Last Name *
Your answer
Grade Entering Fall of 2018 *
Date of Birth *
MM
/
DD
/
YYYY
Address with City, State & Zip Code *
Your answer
Student Cell Phone *
Your answer
Student Email *
Your answer
Mother's Name *
Your answer
Mother's Phone Number *
Your answer
Mother's Email *
Your answer
Father's Name *
Your answer
Father's Phone Number *
Your answer
Father's Email *
Your answer
Emergency Contact Name *
Your answer
Relationship *
Your answer
Emergency Contact Phone Number *
Your answer
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