Name of Child
Child Home Address

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Does your child have any medical concerns, allergies, or physical limitations? Please list all:
Huntington (Countrywood School): What days would you like to register for?
Will a third party be covering the cost/partial cost for the program?
Parent/Guardian 1
Emergency Contact 1
Must include someone other than Parent/Guardian
Emergency Contact 2
Must include someone other than Parent/Guardian
Please type your name
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