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2. 
4. Parent First & Last Name
6. First & Last Name of children in attendance.
8. Address
10. City
11. State
12. Zip Code
14. Phone Number
16. Email Address
20. Select an option below regarding persmission for images and recordings to be used by TCHD for educational and/or promotional purposes.

    1. Permission granted
    2. Permission is not granted
22. Client/Parent/Guardian e-Signature
24. Date
    Date
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field