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Students Name
Age
*
Must be 5 by September 30, 2019
Gender
Last Grade Completed
Parent / Guardian Name
Name on Credit Card
*
Home Address
Home Phone
Cell Phone
Email Address
Emergency Contact Name
Emergency Phone
Who will be picking up your child
List any allergies your child has
Session 1 (July 8-12) First Choice
Session 1 (July 8-12) Second Choice
Session 2 (July 15-19) FirstChoice
Session 2 (July 15-19) Second Choice
I GIVE permission for photographs of my child to be placed in local newspapers and/or on the PBAA website. The child's name will NOT be listed.
*
Yes
No
Please check the required fields
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