Child's name: Age:Gender:
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Parent/Guardian:Home phone with area code:
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Street:E-mail Address:
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City:State:Zip:
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Parent/Guardian Cell phone:Work Phone:
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Emergency name and contact number:
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Please tell us about any issues we should be aware of regarding your child such as Allergies/Medications/Behavioral:
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I wish to pay by credit card: _____VISA _____MASTERCARD ____AMERICAN EXPRESS ____DISCOVER
Credit Card Number ___________________________________________________ Exp.Date__________
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Parent Signature:
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How did you hear about us? ____Newspaper ___Magazine ___Friend ___Brochure ____Flyer
____Internet ___Other (Explain_________________________________________)
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