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Name <br />Address <br />Phone(H)(___) <br />Male <br />Email <br />Female <br />Special Needs, Allergies, Medical <br />Method of Payment: Check <br />Expiration Date <br />Exact name on Card <br />(w)U <br />Program# <br />Cash <br />Credit Card # <br />Parent /Guardian <br />City <br />Class <br />B irthdate <br />Zip <br />Charge Charge: VISA MasterCard AC <br />