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First Name:

(Primary Contact)

Last Name:

(Primary Contact)

Language:

Birthdate:

Gender:

Address:

City:

Country:

State:

Zip:

Phone:

(ex: XXXXXXXXXX, Non US/Canada start with +)

Health Notes:

Emergency Contact:

Emergency Phone:

(ex: XXXXXXXXXX, Non US/Canada start with +)

The Minnesota Data Privacy Act requires that we inform you of your rights about the private data we are requesting on this form. The following data contained on this form will be considered private data pursuant to M.S. 13.548, the name, address, telephone number, any other data that identifies the individual, and any data that describes the health or medical condition of the individual, family relationships, and living arrangements of an individual or which are opinions as to the makeup or behavior of an individual. We need this data to register you for a program and to contact you if necessary. Edina staff will have access to the data you provide to administer the program. You are not legally required to provide the data; however, refusing to supply the data may cause your registration to not be processed. By creating an account you agree to the Minnesota State Data Practices Act. :

Email:

Password:

Verify Password:

Password Requirements: Between 8-16 characters, 1 alphabetic, 1 numeric, 1 special character (!@#^*-=), no spaces

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Family Members:

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