| Name: * |
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| Address: * |
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| State: * |
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| Zip: * |
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| Home phone: * |
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| Cell phone: |
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| E-mail: * |
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| Child one: * |
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| Child two: |
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| How many children do you have in PYSA?: * |
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| Does your child/children play club soccer?: * |
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| Does your child/children play other sports?: * |
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| Does your child/children receive free or reduced lunch?: * |
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| Have you ever received a prior scholarship from PYSA?: * |
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| Comments or additional information: |
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