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FAMILY INFORMATION (ALL)

Please complete the form below. Required fields marked with an asterisk *

Child's Full Name*

Answer Required

Class*

Answer Required

Name to be used in class*

Answer Required

Date of Birth*

Answer Required

Sex*

Answer Required

Male

Female

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Religious Affiliation*

If none, please type N/A.

Answer Required

Contact Information

Parent 1

Full Name*

Answer Required

Address (only if different from child's)

Street Address

Answer Required

City

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Zip/Postal

Answer Required

Email 1*

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Mobile Phone*

Number Required

Home Phone

Number Required

Place of Employment *

If none, please type N/A.

Answer Required

Occupation *

If none, please type N/A.

Answer Required

Work Phone

Number Required

Parent 2

Full Name

Answer Required

Address (only if different from child's)

Street Address

Answer Required

City

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Zip/Postal

Answer Required

Email 2

Answer Required

Mobile Phone

Number Required

Home Phone

Number Required

Place of Employment

Answer Required

Occupation

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Work Phone

Number Required

Child's Parents are:

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Married

Divorced

Separated

Widowed

Other:

Please list names, ages, and current schools of any siblings.*

If none, please type N/A.

Answer Required

Emergency Contacts

#1 Name*

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Relationship*

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Phone/Cell #*

Number Required

#2 Name*

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Relationship*

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Phone/Cell #*

Number Required

Insurance Information

Insurance Carrier*

Answer Required

Subscriber Name*

Answer Required

Group Number*

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ID Number*

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Confirmation Email

Email Required