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1. What is your first name?

2. What is your last name?

3. What is your street address?

4. In what city do you live?

5. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

6. What school do you attend?

7. Grade:

8. Parent's Name

9. Address if different than address above

10. Email Address

11. Phone Number

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