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I certify that I accurately completed this form and if anything changes I will notify the provider by updating this form. Signature of Parent or Guardian Date Card Reviewed Date Signed Parent or Legal Guardian Initials AUTHORITY 1973 PA 116 LARA is an equal opportunity employer/program. COMPLETION Required PENALTY Rule Violation. Hawks Discovery Preschool licensed by the Department of Licensing and Regulatory Affairs to secure I give permission to Little emergency medical for the above named...
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