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MODE SUMMER CAMP EMERGENCY FORM 2018 (OLD)
STUDENT Last Name
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First Name
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Date of birth:
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PARENT Last Name
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First Name
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Gender
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male
female
non-binary
PRIMARY Phone Number
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We want to create a successful experience for your child. Please explain any Please explain your child's serious health condition: (for example diabetes, severe allergies, epilepsy/seizure disorder, severe asthma or cardiac/heart conditions.)
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