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Child's First and Last Name
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Child's Birthday
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Month
Day
Year
Child's Age
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Food Allergies/Med Consid
Parent/Guardian's Name
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Parent/Guardian's Phone Number
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Alternate Phone Number
Parent/ Guardian's Email
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Street Address, City, State, Zip Code
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I grant permission to use photos and/or video recordings of the child listed above. I understand that these images may be used in print, online, and on social media.
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