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XYZ Registration 19/20
XYZ 19/20: August 2019 - June 2020
Address: 26 Union St
Contact us at (802) 521-7948 or
info@eemc2.com
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Email
*
Your email
Participant's (Child's) Name
*
Your answer
Parent's (Main Contact) Name
*
Your answer
Participant's (Child's)Address
Your answer
Gender:
Female
Male
Prefer not to say
Prefer to describe
Non-Binary/Third Gender
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Age of Participant
Your answer
Grade
Your answer
Primary Phone
*
Your answer
Secondary Phone
Your answer
Emergency Contact
*
Your answer
Relationship to Participant (Child)
*
Your answer
Emergency Contact Main Phone
*
Your answer
What days will you attend? Select all that apply.
*
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
All Days
Other:
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I understand and agree to abide by the rules of E=MC2 and that coming to the Community Center is a privilege.
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