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GraceLife Ascend • 705 Lakeview Dr. Pineville NC

Student Name

Date of Birth

Address

Gender

School Name

Teacher's Name

T-Shirt Size

Mother/Guardian Name

Mobile Phone Number

Address (If different from Student)

Father/Guardian Name

Mobile Phone Number

Address (If different from Student)

Emergency Contact

Relationship To Student

Emergency Contact Number

Emergency Contact

Relationship To Student

Emergency Contact Number

Limited spots are available register today!