| Child's First Name: * |
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| Child's Last Name: |
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| School Grade: * |
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| Child's Birthdate: * |
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| Child's Baptism Date: |
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| Child's Age: * |
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| Can the child read?: |
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| Is the family a member of Epiphany Lutheran Church?: |
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| Parent's Names: * |
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| Home Address: * |
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| Primary Phone: * |
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| Alternate Phone: |
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| Parent's Email Address: |
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| Student's Email Address: |
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| Emergency Contact: * |
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| Contact's Relationship to Student: * |
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| Contact's Primary Phone: * |
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| Contact's Alternate Phone: |
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| People Who Can Pick-up Child: * |
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| List Any Food Allergies: |
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| List Any Other Allergies: |
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| Explain Additional Medical Concerns: |
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| Additional Information You Would Like the Teacher to Know: |
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| Family Doctor's Name: * |
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| Family Doctor's Phone: * |
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| Preferred Hospital Name: * |
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| Preferred Hospital Phone: * |
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| Family Dentist Name: * |
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| Family Dentist Phone: * |
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| Photo Release: I hereby grant permission to photograph/film the minor designated above in any manner or form for any lawful purpose associated with the Sunday School program. (Type yes or no): * |
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