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First name
*
Last name
*
Date and time
*
Month
Month
Day
Year
Time
:
Hours
Minutes
AM
County
*
School:
Are you a:
*
Student
Educator
Parent
Are you willing to stay home from school (Go on strike) for up to or exceeding 1 (one) month, if needed?
*
Yes
No
Type your signature here:
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Do you consent to this form being stored and used as your digital signature?
*
Yes
Submit
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