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Parent/Guardian First Name

Parent/Guardian Last Name

Phone Number

Email Address

Anticipated Start Date

Age of Child(ren) at Start Date: [Check all that apply] Age of Child(ren) at Start Date: [Check all that apply] Under 12 months 12-18 months 19 months - less than 3 years 3-6 years, not in school Kindergarten Grade 1-6

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