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Parent Information
Parent/Guardian Name   ex. Sue
Parent/Guardian Name   ex. Bob
Family Name   ex. Jones
CHC Alumni?  N 
Alumni's Name  Year 
Student Information
Student #1
Child's First Name
Child's Last Name
Child's Gender  F 
Child's Birth Date   Day:  
Student #2 (leave blank if not applicable)  expand
Student #3 (leave blank if not applicable)  expand
Contact Information
Email
Address1
Address2
City
State
ZIP
Phone  [123-456-7890]
Additional questions/comments?