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Additional Info
Emergency Contact Info
Contact #1
Contact #1 First Name
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Last Name
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Type
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a1 Family: Mother
a2 Family: Father
Family: Adult Student
Family: Grandparent
Family: Guardian
Family: Other
Family: Step Father
Family: Step Mother
Parent
Professional: Doctor/Physician
Professional: Student's School-Counselor
Professional: Student's School-Other
Professional: Student's School-Teacher
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Email
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Contact #2
Contact #2 First Name
Last Name
Type
a1 Family: Mother
a2 Family: Father
Family: Adult Student
Family: Grandparent
Family: Guardian
Family: Other
Family: Step Father
Family: Step Mother
Parent
Professional: Doctor/Physician
Professional: Student's School-Counselor
Professional: Student's School-Other
Professional: Student's School-Teacher
How can we contact you?
Home Phone
Work #
Cell #
Email
(Emails are kept confidential)
Confirm Email
Student #1
Student's First Name
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Last Name
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Student Gender
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Female
Male
Birth Date
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Additional Info
Student Email
T-Shirt Size
School
Grade Level
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
college-freshman
college-junior
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college-sophomore
kindergarten
pre-K
preschool
Disabilities (Leave blank if NONE)
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Primary Doctor
Student #2
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Student's First Name
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Last Name
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Student Gender
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Female
Male
Birth Date
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Additional Info
Student Email
T-Shirt Size
School
Grade Level
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Disabilities (Leave blank if NONE)
Allergies (enter "none" or specify)
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Medications (enter "none" or specify)
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Primary Doctor
Student #3
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Student's First Name
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Last Name
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Student Gender
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Female
Male
Birth Date
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Additional Info
Student Email
T-Shirt Size
School
Grade Level
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Disabilities (Leave blank if NONE)
Allergies (enter "none" or specify)
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Medications (enter "none" or specify)
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Primary Doctor
Student #4
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Student's First Name
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Last Name
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Student Gender
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Female
Male
Birth Date
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Additional Info
Student Email
T-Shirt Size
School
Grade Level
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Disabilities (Leave blank if NONE)
Allergies (enter "none" or specify)
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Medications (enter "none" or specify)
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Primary Doctor
Student #5
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Student's First Name
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Last Name
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Student Gender
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Female
Male
Birth Date
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Additional Info
Student Email
T-Shirt Size
School
Grade Level
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Disabilities (Leave blank if NONE)
Allergies (enter "none" or specify)
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Medications (enter "none" or specify)
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Primary Doctor
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Enter your Full Name
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November 21, 2024
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