Instructions

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Please fill out the following form fields and click on the next button below. Fields indicated by a red (*) asterisk are required fields.

Student Information

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First Name*	Required	Last Name*	Required	Middle Initial
Home Phone*	Required	Birth Date*	Required	Gender *	Male Female Required
Home Address:
House Number*	Required	Street*	Required	Apt/Box
City *	Required	State		Zip Code*	Required
Resident Public School District*	Required
Primary Contact Name*	Required
Contact Email			Mobile Phone / Text message Contact (SMS)

School Information

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Student's Grade*	Required	School Name*	Required	City*	Required
Special Comments
	(Comments are limited to 90 characters including spaces)