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Student's First Name
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Student's Last Name
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Student's Date of birth
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Day
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Month
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Year
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2018
Student's Gender
*
Select...
Male
Female
Name of the last school the student attended
*
What was the student's percent average last term?
*
What is student's current grade? (1-12)
*
Region
*
Select region
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Village
*
Email address
*
Phone number
*
+592
Password
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Minimum 8 characters
(0 / 8)
Strength: Too short
Confirm Password
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