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Child's name: (First, Middle, Last.)
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Boy or Girl?
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Time of birth: (Please indicated A.M. or P.M.)
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Date of birth: (including weekday)
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Birth length:
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Birth weight:
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Birth place: (City & State)
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What color mat would you like? (Pink, Royal blue, Light blue, Yellow, or Pine green.)
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Deliver to: (name, address, city, state, & zip code)
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From:
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Are you a California Resident?
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What is your email address? (This is where you'll recieve a payable invoice via Pay Pal.)
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Please enter your Gift Cetificate # (if applicable)
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How did you hear about HappyChaps?
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Additional notes or comments:
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