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Contact Information
Please enter your full name.
Please enter your full address.
Please enter your contact phone number in the following format: XXX-XXX-XXXX.
Other Information
Enter the name of the school you attend.
Enter your grade.
Enter the NAME and NUMBER of the person to call in the event of an emergency.
Let us know if you have any medical issues we would be aware of.
Parent/Guardian Information
Enter the full name of a parent of guardian (if under 18 years old).
Enter the phone number for a parent of guardian (if under 18 years old).
Councils and Committees

For more information, please contact: Jesse Mancinone, Prevention Coordinator 203-578-4044 or you may email him at cnvracprevention@sbcglobal.net or send this form to: CNVRAC, 22 Chase River Road, Waterbury, CT 06704; Fax: 203-756-6032