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Core Class Payment Form
Primary Caregiver's Information
*
First Name
Last Name
Primary Caregiver's Relationship to Child
*
select one
Parent
Grandparent
Other (Please describe)
Email
*
Verify Email
*
Phone
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Amount
*
$
Child's Information
*
First Name
Last Name
Child's Date of Birth
*
(mm/dd/yyyy)
Child's Gender
*
select one
Female
Male
Gender Nonconforming
Transgender
Prefer not to respond
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