Todays' date:
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Childs' legal first name:
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Childs' legal middle name:
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Childs' legal last name:
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Childs' date of birth:
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Childs' gender at birth:
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Please upload proof of age:
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Custody:
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Court orders:
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Childs' home address:
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Language spoken at home:
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Which Strong Start program will you attend most often:
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Does the child have a life threatening illness?:
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Does the child have a non-life threatening illness?:
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Parent / Guardian Information
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Parent / Guardian name:
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Parent / Guardian type:
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Guardians' home address:
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Primary phone number:
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Alternate phone number:
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Email address:
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Place of Employment:
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Alternate Emergency Contact (custodial parents will always been contacted first)
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Emergency Contact Name:
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Emergency Contact Telephone:
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Can this person pick-up the child:
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Alternate Emergency Contact Name:
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Alternate Emergency Contact Telephone:
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Can this person pick-up the child:
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