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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*

    YesNo 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*