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FIRST
NAME: |
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| LAST NAME: |
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| PARENT FIRST NAME: |
Please type name or
n/a. Can not be blank. |
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STREET: |
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CITY: |
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STATE: |
must live within three hours drive
of Cleveland or Toledo. |
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ZIP: |
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| VERIFY LOCATION: |
I live within a
three hour drive of Cleveland or Toledo
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| HOME PHONE: |
xxx-xxx-xxxx |
| E-MAIL: |
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| AGE: |
age 3 1/2 and
older ONLY |
| DATE OF BIRTH: |
mm/dd/yyyy |
| HEIGHT: |
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| GENDER: |
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COMMENT: or
QUESTION:
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