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First Name

Last Name

Gender

Grade completed

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Parent/Guardian

Phone Number

Email

Emergency contact

Relationship to child & phone number

Who can pick up your child?

Name of home church

Food allergies: Yes or No (If yes, please list.)

Medical Concerns: Yes or No (If yes, please list.)

Permission To Use Images and Video

Parent/Guardian signature (Please type name)

Date