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Registration Information
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First Name
Last Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
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First Name
Last Name
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First Name
Last Name


First Name
Last Name


First Name
Last Name


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I give permission for my child to have his/her picture or video taken a the Chautauqua Children's Safety Education Village and to have these photos or videos as a part of a press release, on our website, in any media including Facebook, Instagram and other social media sites, on television, in videos created to display our classes for advertising purposes. I confirm that I am the legal parent or guardian of the child on this application form.
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