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181 182 3290. 124 a b 3290. 181 182 Does your child have an IEP YesNo Child s Gender MaleFemale Child s Name Birthdate Home Address Email Address Mother s Name/Legal Guardian Home Phone Cell Phone Business Name Business Phone Emergency Contact Person s - Name Phone Number when child is in care Person s to Whom Child may be released Name/Address Name of Child s Physician/Medical Care Provider Address Special Disabilities if any Allergies including medicine reaction Medical or Dietary...
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