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sysmgr.gary
2016-12-20T13:36:13+00:00
Student Name
*
First
Last
Name of Elementary School
*
Grade
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Grade 1
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Teachers Name
Parent Name #1
*
First
Last
Parent #1 Cell Phone
*
Parent #1 Home/Work Phone
Parent #1 Email
*
Parent Name #2 (optional)
First
Last
Parent #2 Phone (optional)
Parent #2 Email (optional)
Program Desired
*
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Billing Address
*
Street Address
Address Line 2
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PICK UP INFORMATION (fill out for after-school programs only)
Name Of Pick up Person One
Name Of Pick up Person Two
Or I give my child permission to walk home
Total
$ 0.00 CAD
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Expiration Date
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Cardholder Name
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