AGAPE LIFE STEM AFTER-SCHOOL PROGRAM                                                                                         8568  Laureldale  Dr,                                                  Laurel,  MD 20724                 Phone:       (301)-725-6525 or                                               (301)-828-6664
AGAPE LIFE STEM AFTER-SCHOOL PROGRAM APPLICATION
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Email *
CHILD #1
First Name *
Last Name *
Date Of Birth *
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Gender *
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Grade *
Ethnicity: *
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CHILD #2
First Name
Last Name
Date Of Birth
MM
/
DD
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YYYY
Gender
Grade
Ethnicity:
CHILD #3
First Name
Last Name
Date Of Birth
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/
DD
/
YYYY
Gender
Grade
Ethnicity:
Address *
City *
State *
Zip Code *
Home Phone *
Cell Phone *
Work Phone *
Emergency  Contact  Info (Contact  Name): *
Phone Number *
Relationship  to  child: *
Allergies *
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If YES Please List
PARENT *
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Authorized  persons  to  pick  up  my  child(ren)  are : First & Last Name(s)
Phone Number(s)
If  under  18 years  of  age  please  notify  staff.  My  signature  authorizes  my  child  to  be  picked  up  only  by  the  persons  I  have listed  on  this  form  unless  otherwise  notified  in  writing.
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