Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Your Name *

First Name

Last Name

Your Phone Number *

(###)

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Your Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

In Case of Emergency (ICE) Contact Name

First Name

Last Name

ICE Contact Phone Number

(###)

###

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