1. Child Information

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1. School (Required.)

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2. Last Name (Required.)

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3. First and Middle Names (Required.)

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4. Preferred Name

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5. Birthdate (Required.)

Date

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6. Gender (Required.)

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7. Home phone (Required.)

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8. Cell phone (Required.)

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9. Primary Address (Required.)

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10. Mailing address if different from Q9

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12% of survey complete.

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