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Child/Adolescent Information
Parent/Guardian: Please fill out your child's information to the best of your ability. Information provided on this form is confidential.
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Child's Full Name
*
Your answer
Preferred Name / Nickname
Your answer
Parent/Guardian(s) Name(s)
*
Your answer
Address
*
Your answer
Email
*
Your answer
Phone Number(s)
*
Your answer
Preferred method of contact (Phone, Text, or Email?)
*
Your answer
May we leave messages
*
Your answer
Who should we contact in case of emergency? (Please list name, relation, and contact info).
*
Your answer
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