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Child's Name:
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Child's Age:
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Accompanying Adult's First Name:
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Accompanying Adult's Last Name:
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Child's School:
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Address 1:
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Address 2:
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City:
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State and Zip:
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Email:
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Phone (H):
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Phone (W):
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Phone (C):
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1st Workshop Choice:
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2nd Workshop Choice:
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3rd Workshop Choice:
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4th Workshop Choice:
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Cost:
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*Only if space is available
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