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After School Registration (under 19)

FabNewport Student Registration
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Name *
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Age *
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Gender
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Birth Date *
MM
/
DD
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YYYY
What race or ethnicity is your child? *
Your answer
School *
Your answer
Grade *
Your answer
City/Town/Street *
Your answer
State
Your answer
Zip Code
Your answer
Allergies *
Your answer
Other medical information
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Parent/Guardian Name *
Your answer
Parent/Guardian Phone
Your answer
Parent Guardian Email
Your answer
Other Parent Guardian
Your answer
Other Guardian's Phone:
Your answer
Child's Insurance Information:
Your answer
Does your child receive free or reduced lunch? *
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