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* 1. Full Name:

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* 2. What is your physical address? (please include city and county)

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* 3. What is your e-mail address?

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* 4. What is your phone number?

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* 5. Is this a cell phone?

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* 6. What is the Child's DOB (or Due Date)

Date

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* 7. What is your preferred method of communication?

T