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Participant Name: |
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Birth date: |
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Street Address: |
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Participant’s Primary Phone Number: |
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City, State & Zip: |
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Email or Text Number: |
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Signature
of Parent or Legal Guardian |
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Printed
name of Parent or Guardian |
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Date |
EMERGENCY CONTACT INFORMATION
Parent(s)/Guardian(s)
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Name(s) |
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Parent(s)/Guardian(s)
Primary Phone Number |
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Parent(s)/Guardian(s)
Email address |
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Parent(s)/Guardian(s)
Secondary Phone Number |
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Other Emergency Contact(s)
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Name |
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Phone |
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Relationship to Participant