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Parent Information

Parent 1 First Name:

Parent 1 Last Name:

Parent 2 First Name:

Parent 2 Last Name:

Address:

City/State/Zip

Phone Numbers (day/cell)

Email:

Password:

Confirm Password:

Emergency Contact Information

These should be adults that are not the parents/guardians.

This information will be required before submitting your registration.

Contact #1

Name:

Relationship to child:

Phone:

Email:

Contact #2

Name:

Relationship to child:

Phone:

Email:

Health Provider Information

This information will be required before submitting your registration.

Family Doctor:

Address:

Phone:

Family Dentist:

Address:

Phone:

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