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Initial
Street
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Home Phone
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If under 18
Mother's First Name
Mother's Last Name
Mother's Phone
Father's First Name
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Father's Phone
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Day:
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02
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06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month:
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February
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April
May
June
July
August
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October
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December
Year(yyyy)
Gender
Male
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OHIP #
Doctor's Name
Doctor's Phone #
Allergies or Medical Conditions
In case of emergency contact
First Contact:
Name
Relationship
Address
Phone #
Work #
Cell #
Second Contact:
Name
Relationship
Address
Phone #
Work #
Cell #
Member Status
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Program
Mini-Muskeeters
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