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First name
Last name
Email
Home phone
Cell phone
Mailing address
County
ZIP code
Household primary language
I would need an interpreter or bilingual staff to participate
If other, please describe
Please complete one section for each child enrolled in playgroups.
Child's first name
Child's last name
Date of birth
Food allergies? Yes
If yes, list foods
Medication allergies? Yes
If yes, list medications
Any medical, developmental, or behavioral special needs?
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Name
Phone
Your name (as signature)
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