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Parent or Legal Guardian's Info

Medical and Emergency Contact Information

Please provide emergency contact information for 2 additional adults (must be over age 21 and considered close relatives of the parent and child).
If none, type "N/A"
If none, type "N/A"
Please provide active phone number of emergency contact 1.
Please provide active phone number of emergency contact 1.
Please provide active phone number for emergency contact 2.
Please provide active phone number of emergency contact 1.

Pick Up/Drop Off List

Please list names other than the child's parent, that you allow permission to pick up and drop off for arrival and departure.
Please check all requested days.

Additional Information

Drag your mouse to sign your name or write your name with your finger (if using a touchscreen device) to sign the form.
Price: $ 100.00
$ 0.00
Please provide your PayPal email address so that we can match your payment with your application. If you will not pay online, type N/A.
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