Name of Student *

First Name

Last Name

Students Birth Date *

MM

DD

YYYY

Name of Parent/Guardian *

First Name

Last Name

Parent Phone Number *

(###)

###

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SELECT WHICH CLINICS YOU PLAN TO ATTEND: *

$20 Per Night

RESURRECTION - JAN 28TH @ 6:30PM-7:30PM

RESURRECTION - JAN 29TH @ 6:30PM-7:30PM

RESURRECTION - JAN 30TH @ 6:30PM-7:30PM