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Douglas Police Department Summer Youth Program Contact and Medical form I will attend the July 7-11, 2014 Program I will attend the July 21-25, 2014 Program (Students are welcome to attend both) Students Name: Age: Gender: Physical Address: Phone Numbers: (Please include at least two) Parent/Guardian Adult T-Shirt Size S M L XL Student Name: DOB: Address: Phone Numbers: Please list any physical or medical conditions which may affect the student’s participation in any physical activity, games, climbing wall, etc. Parent of Legal Guardian signature: