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Directory Results for 5/2012 FCA LEADERSHIP TRAINING SCHOLARSHIP FUND Personal Reference (Please submit by June 30) Scholarship Candidate: Your Name: Address: Telephone: Fax: Email: How long have you known the applicant to 5/2014) FRONT NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES CHILD IN CARE MEDICAL STATEMENT To Be Completed By Licensed Physician, Physicians Assistant or Nurse Practitioner Name of Child: Date of Birth: Date of Examination: