Please complete the following information about your household

  1. Head of Household Information
  2. Secondary Guardian Information
  3. Email and Phone Information
  4. Address Information
  5. Emergency Contact Information
  6.   Name of Emergency Contact (First)Name of Emergency Contact (Last)Contact Phone w/ area codeRelationship
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    #2
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  8. Other Information
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  10. Disclaimer
  11. I acknowledge that all information entered is true to the best of my knowledge. I understand that EJRP may need to adjust fees changed for programs if information (such as your residency) is entered inaccurately. All individuals entered in this household are members of the household (not a friend or relative). I am the parent or legal guardian of all minors registered with this household.

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