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* 2. Student's First Name

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* 3. Student's Last Name

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* 4. Address

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* 5. City

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* 6. State

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* 7. Zip

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* 8. Student's Email

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* 9. Age

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* 10. School

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* 11. Grade Level

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* 12. Parent/Guardian Name

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* 13. Relationship to Student

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* 14. Parent/Guardian Contact Number

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* 15. Parent/Guardian Email

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* 16. Medical Information

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* 17. Requested Dates to Page

Page requests will be scheduled between Jan. 7 and April 9th on Monday, Tuesday, or Thursday.

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* 18. How would you like the page information delivered to you?

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* 19. Local Newspaper

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* 20. Would you like to page with a friend?

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* 21. Friend's Name

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* 22. Other Comments

If you have issues with filling out thisĀ application please contact SenateIT@iga.in.gov

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