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	Student Information First Name: * Parent Name: * Middle Name: * Parent Cell Phone: * Last Name: * Parent Email: Address: * Do You have a Permit? -- Select -- Yes No City: * If Yes - Permit #: State and Zip: -- Select -- MD * Gender: -- Select -- Male Female Date Of Birth: Month 01 02 03 04 05 06 07 08 09 10 11 12   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 * High School: -- Select -- Catonsville High School Centennial High School Century High School Glenelg High School Howard High School Kent Island High Liberty High School Loch Raven High School Manchester Valley High School Marriotts Ridge High School Mount De Sales Academy Mt. Hebron High School Other Owings Mills High School RESERVOIR HIGH SCHOOL River Hill High School South Carroll High Winters Mill High School * Student Email: * Wear Glasses/Contacts: -- Select -- Yes No Home Phone: * How Did You Hear About Us: -- Select -- FRIEND Google Search Howard County Times Saw StreetSmarts Car School Advertisement Cell Phone: * Referral Name:
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