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Contact Information:
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Guardian's name (First and Last): *
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Relationship: *
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Home Phone:*
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Work Phone:*
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Cell Phone:*
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Email Address:*
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Student Information:
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Mailing Address:*
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City:*
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State:*
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Zip Code:*
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Student's Name (First and Last):*
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Gender:
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MaleFemale
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Date of Birth:*
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Child's Age:
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Interested in Grade:*
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For School Year:*
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Special Needs:
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YesNo
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Has been or is currently enrolled in the Pepper or Place Programs
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YesNo
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Has an I.E.P. (Individual Education Plan)
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YesNo
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Enter a Matrix Number, if applicable:
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If yes, please explain:
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List Any Medications:
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Add'l Student Name:
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Gender:
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MaleFemale
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Add'l Date of Birth:
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Add'l Child's Age:
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Add'l Interested in Grade:
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Add'l For School Year:
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Add'l Special Needs:
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YesNo
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Has been or is currently enrolled in the Pepper or Place Programs:
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YesNo
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Has an I.E.P. (Individual Education Plan)
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YesNo
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Add'l Enter a Matrix Number, if applicable:
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Add'l If yes, please explain:
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Add'l List Any Medications:
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Please enter comments or information for additional students:
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