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Provider Signature Jane Smith Parent Signature Date 11-29-13 FOR CHILD ACTION INC. USE ONLY. PLEASE DO NOT WRITE BELOW THIS LINE. PARENT and PROVIDER The front of the Attendance Form must be signed and dated by both provider and parent. Child Action Inc. 9800 Old Winery Place Sacramento CA 95827-1700 Parent Child IIIIIIIIIIIIIIIII Smith Jane Smith Michael Provider Acct AX123 Care Code Child DOB 11/27/2007 Fund Case Manager Mario Hernandez 916 274.

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