Student Last Name

Student First Name

Current Grade

Current School

Grade of Interest

• Grade 5
• Grade 6
• Grade 7
• Grade 8
• Grade 9
• Grade 10
• Grade 11
• Grade 12

Parent Last Name:

Parent First Name:

Phone Number

Email

Street Address

City

Postal Code

Do you have any food allergy ?

• No
• Yes*

If yes, please describe:

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