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Registration

Students Name*:
School:*:
Date of Birth*:
Age*:
Gender*: Male Female
Current Grade/ Year of Child*:
Parent/Guardian - name and contact numbers*:
Phone (mom cell)*:
(mom work)*:
(mom home):
Phone (dad cell)*:
(dad work)*:
(dad home):
Email Address*:
Street Address*:
District*:
PO Box*:
Emergency Contact - Name*:
Emergency Contact Phone*:
Is the student allergic to any medications or foods or have any physical conditions (i.e. asthma, diabetes, etc.)?*
 I consent that pictures and/or videos taken in centre of my child may be used for CLC promotional purposes only.
Participant/Guardian Signature*:
Date*:
Additional comments
Accept Terms of Policy and Procedures*:  Yes, I Accept.

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Cayman Learning Centre
Cayman Learning Centre