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Welcome to Arizona Dreams online Waiver and web Registration!
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Referral Information
How did you hear about us?
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Family Information
Family Last Name
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Zip
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Primary Phone
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Additional Info
Emergency Contact Info
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Contact #1
Contact #1 First Name
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Last Name
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Type
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Aunt
Dad
Friend
Grandparent
Guardian
Mom
Other
Parent
Self
Step Father
Step Mother
Uncle
How Can We Contact You?
Home Phone
Work #
Cell #
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Portal Access (your email is your login)
Email
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(Emails are kept confidential)
Confirm Email
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Portal Account Password
Confirm Portal Account Password
Contact #2
Contact #2 First Name
Last Name
Type
Aunt
Dad
Friend
Grandparent
Guardian
Mom
Other
Parent
Self
Step Father
Step Mother
Uncle
How can we contact you?
Home Phone
Work #
Cell #
Receive Text Message Notifications
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
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
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
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
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
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
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
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
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
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
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October 12, 2024
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1st of Month
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