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Bethlehem Academy Athletics Annual Health Questionnaire and Eligibility Statement 2020-2021
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* Indicates required question
Today's Date:
*
MM
/
DD
/
YYYY
Student First Name:
*
Your answer
Student Last Name:
*
Your answer
Gender:
*
Male
Female
Required
Age:
*
Your answer
Birthdate:
*
MM
/
DD
/
YYYY
Grade:
*
6
7
8
9
10
11
12
Required
Parent(s)/Guardian(s)
*
Your answer
Home Phone
*
Your answer
Address
*
Your answer
Work Phone
Your answer
Cell Phone
Your answer
Parent Email Address
Your answer
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