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Em must complete this form. Note: This form should NOT be given to students who are immediately returning from suspension. Please Print Name of Student Requesting Enrollment Age / Date of Birth Address of Student / Grade City Zip City Zip Parent s/ Guardian s Name Address (if different from above) Home Telephone ( ) Work Telephone ( ) Withdrawl Date Last School Attended Address of Last School City State Phone Number of Previous School Identified for Special Education Ser.

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