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Email address *

First Name of Young Person *

Last Name of Young Person *

Birth Date *

Street Address *

Address line 1

Address line 2

Postal Code *

Home Phone *

Mobile Number *

Ethnic Origin Other

Ethnic Origin Information

Please state any activities or hobbies currently of interest to your child:

Please state any information about your child that you think would be useful for us to know (health, behaviour, medication)

Emergency Contact Name and Contact *

School Attended *

Name of Parent, Carer or Guardian *

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