After School Club

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Child's Name: *
Please type name.
Street Address: *
Please type street address.
City: *
Please type city.
State: *
Please select state.
Zip Code: *
Please type zip code.
Home Phone Number: *
Please type phone number.
Cell Number:
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Email Address: *
Please type email address.
School: *
Please type name of school.
Grade: *
Please type grade.
Please check all that Apply.
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Person to contact in case of emergency (not parent/guardian)
Name: *
Please type name.
Phone Number: *
Please type phone number.
Allergies (including food):
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Medications:
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Please type the letters below. Please type the letters below.
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