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Jax PBS Kids Club
Please fill out ALL the following information to enroll your child(ren) into the Jax PBS Kids Club.
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Parent First Name
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Parent Last Name
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Your answer
Mailing Address
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City
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State
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Zip Code
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Your answer
Primary Phone
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Primary Email
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Relationship to Child(ren)
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Mother
Father
Grandparent
Adult Caregiver
Child #1 First Name
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Your answer
Child #1 Last Name
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Your answer
Child's #1 Gender
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Female
Male
Other:
Child's #1 Date of Birth (include year)
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Your answer
Child #2 First Name
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Child #2 Last Name
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Child #2 Gender
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Other:
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Child #2 Date of Birth (include year)
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Child #3 First Name
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Child #3 Last Name
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Child #3 Gender
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Child #3 Date of Birth (include year)
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Child #4 First Name
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Child #4 Last Name
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Child #4 Gender
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Child #4 Date of Birth (include year)
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Child #5 First Name
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Child #5 Last Name
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Child #5 Gender
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Child #5 Date of Birth (include year)
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YYYY
Child #6 First Name
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Child #6 Last Name
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Child #6 Gender
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Child #6 Date of Birth (include year)
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