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Participant Registration

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Registro en Español

Ashtabula PCG

Location

2201 Cook Rd.

Ashtabula, OH 44004

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Contact Gwen Gelofsack:

440-855-9100

apcgkids@gmail.com

First, Tell Us About Yourself:

Parent Information

First Name

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Last Name

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Address 1

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City

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State/Province

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ZIP/Postal Code

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Contact Phone 1

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Text Message Phone

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Emergency Contact Name

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Emergency Contact Relationship

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Do you give permission for participants to be photographed/ video taped for media use?

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Tell Us About Your Participant

First Name

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Last Name

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Date Of Birth

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Gender

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Current Grade

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Allergies

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Medical Concerns

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Comments

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