Parent/Guardian Information
Please enter the name!

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Please provide an username!

Please enter a password!

Retype the password!

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Please provide a valid e-mail!

Please enter the Mailing Address!

Please select the state!

Please select the City!

Please enter the Zipcode!

Please enter the Cell Phone!

Please enter the Home Phone!

Please select Ethnicity!

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Diabetic Child
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Invalid Input

Invalid Input

Invalid Input

Invalid Input

Please select Ethnicity!

Second Child
Invalid Input

Invalid Input

Invalid Input

Invalid Input

Please select Ethnicity!

Third Child
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Invalid Input

Invalid Input

Invalid Input

Please select Ethnicity!

Fourth Child
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Invalid Input

Invalid Input

Invalid Input

Please select Ethnicity!

Medical
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Invalid Input

Invalid Input

Invalid Input