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Parent’s Name *
Parent’s E-Mail *
Parent’s Cell Phone *
Child’s Age *
Do your child have any injuries? * YesNo
If YES, please explain
Does your child have any medical conditions we should be aware of? * YesNo
What are you hoping your child will get out of this class? *
Has your child ever been assaulted or know someone who has? (optional) YesNo
What grade is your child in? *
Is there anything else you would like to let us know?