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Get Da Form 7817

It is necessary for a child to be taken to a medical ROUTINE USES: facility by someone other than the parent. Information on immunization and medical problems will be used as part of the program admission screening procedure. Family income data will be used to determine USDA food program qualification and rate structures. AUTHORITY: Disclosure of requested information is voluntary, however, if information is not provided, individuals may not be allowed to participate in CDS programs. DISCLOS.

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