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Important Information |
| Child's Name: |
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| Date of Birth: | |
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Parent/Guardian Name(s): |
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| Home Telephone: | |
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Work Telephone: |
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Address: |
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Important Health Problems/Allergies: |
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Health Care Provider Name(s) and Phone Number(s): |
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Health Insurance Number(s): |
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| Poison Control Center Phone Number: |
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