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Student Name *

First Name

Last Name

Today's Date

MM

DD

YYYY

Date of Birth

MM

DD

YYYY

Student's primary home address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Address

(If different than the child's)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Cell Phone *

(###)

###

####

Parent/Guardian Alternate Phone Number

(###)

###

####

Parent/Guardian Work or Home Phone number

(###)

###

####

Learning Disabilities

ADD

ADHD

Dyslexia

Other