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2. Last Name
3. First Name
4. Middle
6. Street Address
8. City
9. State
10. Zip Code
12. Home Phone
13. Email Phone
15. Date of Birth
    Date of Birth
16. Age
17. Sex
    -- Select One --MaleFemale
18. Site
    -- Select One --EAST SIDE LOCATION - Delavan Grider Community CenterWEST SIDE LOCATION - Belle Community Center
20. Check all that apply

    1. White
    2. Asian
    3. Native American / Alaskan

    1. Pacific Islander
    2. Black

    1. Hispanic
    2. Other
21. T-Shirt Size

    1. Small
    2. Medium
    3. Large

    1. X-Large
    2. XX-Large

    Please pick one
23. Child Lives With

    1. Mother

    1. Father

    1. Both

    1. Other
25. Parent Name
26. Parent Phone
28. Emergency Contact Name
29. Emergency Contact Phone
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field