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Family Information
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DE
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Additional Info
Emergency Contact Info
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Health Insurance Carrier
Contact #1
Contact #1 First Name
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Last Name
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Type
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Emerg. Cont
Father
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Mother
Nanny
Other
Parent
Step Father
Step Mother
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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
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Last Name
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Type
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Emerg. Cont
Father
Grandparent
Guardian
Mother
Nanny
Other
Parent
Step Father
Step Mother
How can we contact you?
Home Phone
Work #
Cell #
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Email
(Emails are kept confidential)
Confirm Email
Who is your employer?
Employer
Employer Phone
Employer Notes
Student #1
Student's First Name
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Last Name
*
Student Gender
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Female
Male
Birth Date
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Additional Info
Student Email
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 (Leave blank if NONE)
Medications (Leave blank if NONE)
Primary Doctor
Student #2
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Student's First Name
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Last Name
*
Student Gender
*
Female
Male
Birth Date
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Additional Info
Student Email
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 (Leave blank if NONE)
Medications (Leave blank if NONE)
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
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 (Leave blank if NONE)
Medications (Leave blank if NONE)
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
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 (Leave blank if NONE)
Medications (Leave blank if NONE)
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
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 (Leave blank if NONE)
Medications (Leave blank if NONE)
Primary Doctor
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October 14, 2024
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