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KSC Intake Form
Please complete this form so we can directly target your needs. Fill out as many fields that apply and we will reach out to you within 3 business days.  
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First and Last name *
Date of Birth *
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Gender *
Race *
Emergency contact information (name, number, relationship) *
Address *
Phone number *
Which services do you need help with? *
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The information collected will be used only for research for the purposes of Kensington Soccer Club and will not reveal who you are. Federal or state laws may require us to show information to university or government officials (or sponsors) who are responsible for monitoring the safety of our clients . You will not be identified in any publication from our services. Please select if you agree or disagree. *
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