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TK Application Form

To register for this program child must be 5 years old by December 1.
Date

Month Day Year
Student Name*

First Name Last Name
Birth Date*

Month Day Year
Gender

Male Female
Start Date*

Month Day Year
I will be requesting extended care.
Family Information
Parent Name #1*

First Name Last Name
Phone Number*

Area Code Phone Number
E-mail*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parent Name #2

First Name Last Name
Phone Number

Area Code Phone Number
E-mail

Address If differs from above

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty:

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