2022/2023 School Year

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* 1. School (Select only one)

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* 2. Student First Name 

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* 3. Student Last Name

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* 4. Grade:

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* 5. Age:

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* 6. Date of Birth:

Date

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* 7. School ID#:

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* 8. Teacher:

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* 9. Gender:

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* 10. Home Address:

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* 11. Ethnicity:

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* 12. Race (please select only one):

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* 13. Please enter the name (first and last) of the student's parent/legal guardian:

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* 14. What is the above person's relationship to the student?

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* 15. What is the above person's home address,  email, and cell/home phone number?

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* 16. What is the above person's work phone number?

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* 17. If applicable, please enter the name (first and last) of the student's second parent/legal guardian:

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* 18. What is the above person's relationship to the student?

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* 19. What is the above person's home address, email, and cell/home phone number?

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* 20. What is the above person's work phone number?

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