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Student's First name
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Student's Last name
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Student's Address
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Address
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City
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Zip / Postal code
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Birthday
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Month
Day
Year
Student's phone number
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Mother's Name
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Mother's address
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Mother's telephone number
Mother's e mail
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Father's Name
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Father's Address
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Father's telephone number
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Father's e mail address
Name of guardian allowed to pick up student
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Phone Number of guardian
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Student's Primary care doctor
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Primary care doctor's telephone number
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Hospital of Choice
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Signature of Parent
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