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181 182 3290. 181 182 CHILD S NAME BIRTHDATE ADDRESS PARENT/LEGAL GUARDIAN HOME TELEPHONE NUMBER CELL PHONE NUMBER BUSINESS NAME BUSINESS TELEPHONE NUMBER PERSON S TO WHOM CHILD MAY BE RELEASED NAME OF CHILD S PHYSICIAN/MEDICAL CARE PROVIDER SPECIAL DISABILITIES IF ANY ALLERGIES INCLUDING MEDICATION REACTION MEDICAL or DIETARY INFORMATION NECESSARY IN AN EMERGENCY SITUATION MEDICATION SPECIAL CONDITIONS ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD HEALTH INSURANCE COVERAGE FOR CHILD or...
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