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Participants First name
Participants Last name
Birthday
Month
Month
Day
Year
Gender
Email
Phone
Address
Primary Parent/Guardian Name
School your child attends?
What is your child's age and grade?
Are there any medical/allergies?
What is your child's teacher last name?
Parents contact information
Other Authorized person to pick up my child?
Do we have permission to take your child's picture?
Emergency Phone number
Emergency Contact
After Social Skills Club will your child go to ASP?
Do you receive text messages
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