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If you have changed your address, please fill out this form and press "submit" so we may update our records.

* Indicates required information
First Name (Child) * 
Last Name (Child) * 
Date of Birth *  (mm/dd/yyyy)
Phone Number 
OLD Street Address 1 * 
OLD Street Address 2 
OLD City * 
OLD State * 
OLD Zip * 
NEW Street Address 1 * 
NEW Street Address 2 
NEW City * 
NEW State * 
NEW Zip * 
Mom's Name 
Dad's Name 
Additional Kids' Club Members at this address 
Child's Name 
Date of Birth  (mm/dd/yyyy)
Child's Name 
Date of Birth  (mm/dd/yyyy)
Child's Name 
Date of Birth  (mm/dd/yyyy)
Authentication * 

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