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Last First Middle Month/Day/Year
Physical Address:________________________________________________________
Mailing Address: ________________________________________________________
Parent/Guardian Name(s):__________________________________________________
Home phone:___________________________ Work phone:______________________
Email:__________________________________________________________________
Last School Attended:
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School Name City or Town/State
Grade student will be entering:_____________________
Please list any siblings currently enrolled in Leverett Elementary School:
________________________________ _________________________________
Please check yes___ or no ___ if you would like your name given to other residents of your
town for carpooling purposes.
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