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EMERGENCY MEDICAL CARE FORM & EMERGENCY CARE PERMISSION SLIP Child's Full Name Date of Birth Home Street Address City/ST/Zip 1. Parent/Guardian Name Home Phone Mobile Phone Home Street Address City/ST/Zip

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Note this entire form can be filled out by providing accurate and complete information in the designated sections.

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The purpose of note this entire form is to collect and report necessary information as required by the governing body.

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