Please check each event you are registering for!
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Your Total Cost = $0

 IMPORTANT!

Student Information
First Name:
Last Name:
Street Address:
Apt #:
City:
State:
Zip:
Home Phone:
Student Cell Phone (if you have one):
Grade as of September 2008:
Contact Information
Mother's First and Last Name:
Mother's Cell Phone:
Mother's Work Phone:
   
Father's First and Last Name:
Father's Cell Phone:
Father's Work Phone:
   
Emergency Contact (if parent unreachable):
Emergency Contact's Relation to Student:
Emergency Contact's Phone:
Medical Information
Primary Care Physician:
Insurance Company:
Policy Holders Name:
Insurance Number:
Insurance Group Number:
Specific Allergies:
List any medications you are taking:
Payment Information
Name as it appears on the credit card being used to pay: