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* 1. Child's First Name

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* 2. Child's Last Name

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* 3. Male/Female

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* 4. Address

If there is only one parent/legal guardian please enter the same information for questions 4 -9.

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* 5. Mother's Name/Legal Guardian

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* 6. Mother's Email

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* 7. Mother's Phone Number

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* 8. Father's Name/Legal Guardian

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* 9. Father's Email

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* 10. Father's Phone Number

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* 11. Child's Birthdate

Date

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* 12. Name of  Child's Physician/Medical Care Provider

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* 13. Address of Physician/Medical Provider

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* 14. Health Insurance provider

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* 15. Policy Number

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* 16. Please List Known Allergies

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* 17. Medications we need to be aware of

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* 18. Has your child been evaluated or currently getting support or special services? if yes, please explain.

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* 19. Any additional information on Special Needs of Child?

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* 20. I'm interested in enrolling my child in the following program

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