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Ts to attend: For the: Summer Fall Spring Alameda Year: Berkeley 20 Laney Merritt H.S. Grade Level (on the 1st day of the college term): High School Student s Information Student s Name: Last Name First Name Social Security #: M.I. Date of Birth: Address: Street City, State Phone #: Zip Email Address: H.S. Student s Signature: Date: Parent or Guardian s Signature: Date: I hereby certify that I am the parent/guardian of the above-named student and am in agreement w.

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