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Child's Name:  * 
Gender: Male Female  * 
Birthdate  * 
Grade Completed  * 
Address
City State Zip
Parent/Guardian  * 
Home Phone  * 
Work Phone Cell  * 
Email  * 
Emergency Contact
Relationship to Child  * 
Phone:  * 
Name of home church
Food Allergies Y N  * 
List  * 
Medical concerns Y N  * 
Explain
Your Email Address  * 
 
 
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