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REGISTRATION FORM

Please print clearly with black or blue ink.

Child's Full Name :
DOB :
Address:
Home Phone :
City : State: ZipCode:
Nickname :
Mother's Full Name : Home Phone :
Occupation :
Name of Employer:
Work Phone :
Cell Phone :
Business Address :
City : Work Hours :
Father's Full Name : Home Phone:
Occupation :
Name of Employer:
Work Phone
Cell Phone
Business Address :
City : Work hours:
Parent/ Guardian with legal custody :
Parents are : Married Living together Divorced Separated Widowed Single 
Other household members:
Name : Age: Relationship:
Name: Age: Relationship: