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| Parent/Guardian/Custodian Contact Information: |
| Relastionship to Recruit(s) Below: |
| Last Name: First Name: |
| Street Address: |
| City: State: Zip: |
| Primary Telephone: Alternative Telephone: |
| Alternative Email (optional): |
|
| 1. Potential Recruit Information: |
| Last Name: First Name: Sex:
Age: |
| Additional Information/Comment: |
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| 2. Potential Recruit Information: |
| Last Name: First Name: Sex:
Age: |
| Additional Information/Comment: |
|
| 3. Potential Recruit Information: |
| Last Name: First Name: Sex:
Age: |
| Additional Information/Comment: |
|
| 4. Potential Recruit Information: |
| Last Name: First Name: Sex:
Age: |
| Additional Information/Comment: |
|
