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Kicking Bear Registration Form
Deerassic Park Education Center
14250 Cadiz Road
Cambridge, Ohio 43725
http://www.deerassic.com
Child Information
First Name
Last Name
Sex
M
F
Birth Date
Grade
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
First Name
Last Name
Sex
M
F
Birth Date
Grade
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
First Name
Last Name
Sex
M
F
Birth Date
Grade
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
First Name
Last Name
Sex
M
F
Birth Date
Grade
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
First Name
Last Name
Sex
M
F
Birth Date
Grade
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Parent / Guardian Contact
Relationship to Participants:
*
Mother
Father
Guardian
Guardian
First Name
*
Last Name
*
Address 1
*
Address 2
City
*
State
*
Zip
*
Phone
Alternate Phone
Email Address
*
Special Instructions
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