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N I - TO BE COMPLETED BY PARENT(S) Child s Name (Last) (First) Date of Birth Gender Male Does Child Have Health Insurance? Yes / Female / If Yes, Name of Child's Health Insurance Carrier No Parent/Guardian Name Home Telephone Number Work Telephone/Cell Phone Number Parent/Guardian Name Home Telephone Number Work Telephone/Cell Phone Number I give my consent for my child s Health Care Provider and Child Care Provider/School Nurse to discuss the information on this form. Signa.

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