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STUDENT INFORMATION

First Name*

Last Name*

Date Of Birth*

School Name*

Grade*

Gender*

Street Address*

Apt.#

City*

State*

Zipcode*

PARENTS INFORMATION

Father's Name*

Email*

Contact Number*

COMMENTS

EMERGENCY CONTACT

Name*

Contact Number*

 Yes No I allow to use my child's pictures, videos, academic achievements and testimonails in both print media and webpages such as facebook.

I certify that the informatin given above is true to the best of my knowledge.

Name*

Date*