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1 Name Relationship to child Street Address City State Zip Code Postal Cell Phone Home Phone Work Phone Medical Information Physician s Name Phone Number Insurance Company Name or Medi-Cal Policy Number or Medi-Cal Allergies/Special Health Considerations In case of an accident or an emergency I authorize a Santa Rosa Junior College Children s Center staff member to obtain all emergency or dental care at the nearest emergency hospital and consent to emergency treatment and measures deemed...
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