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Your signature authorizes the responsible person at the child care facility to have your child transported to that hospital. Signature of Parent/Guardian Date Child s Name Enrollment Date Birth Date Hours Days of Expected Attendance Child s Home Address Mother s Name Home Telephone Mother s Employer/School Address Name Mother s Home Address If different from above Work Telephone Cellular Phone Beeper Beeper Name of Person Authorized to Pick Up Child daily Relationship to Child ANNUAL UPDATES...
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