Student's Name
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Student's Story
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Student's City of Residence
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Name of School Student Attends
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Upload Image
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Nominator's Name
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Nominator's E-Mail Address
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Nominator's Phone Number
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Is Nominator also the parent/guardian?
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Yes
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Parent's Name
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Parent's E-Mail Address
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Parent's Phone Number
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How did you hear about the Superior Plumbing Kids Club?
I have the right to use this image and story, and extend that right to Superior Plumbing
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I Agree
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