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Address
_____________________________________________________________
City
______________________ Zip Code __________________________
Phone
___________________ E-mail _____________________________________
Parent’s Name
________________________________________________
Parent’s Work
Phone ________________ Parent’s Cell Phone _____________
Emergency Contact
_______________ Emergency Phone ______________
Allergies or Other
Medical Conditions ______________________________
Birth date
____________________ Last Grade
Completed _____________
Person Allowed to
Pick-up my child ________________________________
Phone
___________________________
Name of Home
Church __________________________________________
Circle size:
(youth small) (youth medium) (youth large) (adult small)
(adult
medium) (adult large) (adult x-large) (adult xx-large)
