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| Parent's Names _______________________________ |
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| Address _____________________________________ |
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| _____________________________________ |
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| Home Phone # _______________________________ |
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| Work Phone # ________________________________ |
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| Emergency Contact (Name and Phone #) ___________________________________________ |
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| ____________________________________________ |
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| E-mail address- _______________________________ |
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| CHILD'S NAME _________________ Age______ |
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| D.O.B.___________________ |
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| Class Name________________Amount____________ |
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| Class Name________________ Amount__________ |
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| Class Name________________ Amount__________ |
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| Class Name________________ Amount__________ |
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| Class Name________________ Amount__________ |
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| Class Name________________ Amount__________ |
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| Class Name________________ Amount__________ |
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| Class Name________________ Amount__________ |
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| Total Due per quarter___________________ |
| Registration Fee_______________________ |
| Balance Due__________________________ |
| Check Number________________________ |
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