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Street City Zip Code Birth Date: Phone Gender: Male Female Email 3 year old class (by 9/1/12) Prefer T/T Prefer W/F No Preference 4 year old class (by 9/1/12) Prefer A.M. Prefer P.M. No Preference 4/5 year old class (5 by Dec. 1, 2012) Meets T/W/T/F With whom is the child living? Father's Name: Where employed? Occupation: Phone: Mother's Name: Where employed? Cell Phone: Occupation: Phone: Cell Phone: Names and ages of brothers Names and ages of sisters Has your child attended.

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