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* 1. Student Name

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* 2. Date of Birth

Date

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* 3. Grade Level in 2023-24

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* 4. Address

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* 5. City/Town

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* 6. State/Province

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* 7. ZIP / Postal Code

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* 8. Phone Number

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* 9. Email Address

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* 10. For informational purposes, is your student interested in attending On-Site classes?

T