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Parent Information
Parent/Guardian Name *
Parent/Guardian Name
Parent/Guardian Name
Parent/Guardian Name
CHKP Alumni? *
Student #1's Information
Child #1's Name *
Child #1's Name
Child #1's Gender *
Child #1's Birth Date
Child #1's Birth Date
Student #2's Information
Leave blank if not applicable
Child #2's Name
Child #2's Name
Child #2's Gender
Child #2's Birth Date
Child #2's Birth Date
Student #3's Information
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Child #3's Name
Child #3's Name
Child #3's Gender
Child #3's Birth Date
Child #3's Birth Date
Contact Information
Phone *
Phone
Address
Address