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* 1. Student's First Name

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* 2. Student's Last Name

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* 3. Student's Cell Phone

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* 4. Address

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* 5. City

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* 6. State

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* 7. Zip Code

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* 8. Birthdate

Date

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* 9. Grade

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* 10. Gender

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* 11. Age

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* 12. School

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* 13. Primary Parent Guardian Contact (Please Respond With Mom / Dad / Other)

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* 14. Primary Contact Name

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* 15. Primary Contact Home Phone

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* 16. Primary Contact Cell Phone

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* 17. Primary Contact Email

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* 18. Secondary Contact (Please Respond With Mom / Dad / Other)

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* 19. Secondary Contact Name

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* 20. Secondary Contact Home Phone

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* 21. Secondary Contact Cell Phone

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* 22. Secondary Contact Email

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* 23. Person Other Than Parent to Contact in Case of Emergency Name

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* 24. Person Other Than Parent to Contact in Case of Emergency Phone

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