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Keepsafe Application - After-School 2023-2024
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Email
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Student Full Name
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Date of Birth
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YYYY
Sex:
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Female
Grade Level
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Last 4 of Social Security
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School Name
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Student ID Number
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Date of Enrollment
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DD
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YYYY
Address
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Mother's Name
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Father's Name
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Home Phone
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Cell Phone
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Work Phone
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Medical Information: Doctor
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Medical Information: Doctor Phone Number
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Medical Information: Hospital Preference
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Please list allergies, special medical or dietary needs, or other areas of concern
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Emergency Contact Name
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Emergency Contact Number
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Emergency Contact Name
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Emergency Contact Number
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Emergency Contact Name
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Emergency Contact Number
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Helpful Information about your child
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