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EPSD Registration Form East Penn School District Emergency Contact/Health Information School Year 2012/2013 Name of student ID Last First MI Street Address Gender M F Grade/Homeroom Birth Date 1st Contact 2nd Contact 3rd Contact First Name Middle Name Last Name Relationship Home Phone Cell Phone Work Phone Physician Phone Hospital Choice Medical Conditions/Allergies Current Medications EPI PEN yes no Name of Medication Dosage Time given Parent Signature Date.

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