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*Learner's First Name: |
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*Learner's Last Name: |
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*Parent/Guardian Name: |
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*Address: |
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*City: |
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*State: |
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*Zip: |
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Home Phone: |
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Cell Phone:
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Email: |
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*Birthday: (12/31/2006) |
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*Last Grade Completed: |
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Allergies, Medical, & Special Needs:
(Leave Blank if None) |
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*Emergency Contact Name (1): |
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*Emergency Contact Phone (1):
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*Authorized Pickup #1: |
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Are you a member of SHBC? |
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Guest of: |
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Do you attend Church? |
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If so, where? |
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May we photograph your
child? |
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May we have permission to use your child's
photograph in church publications? |
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Gender: |
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