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): Home Ph. (if different) Parent / Legal Guardian's Name Address (if different from above) Work Ph. Cell Other Ph. Home Ph. (if different) Parent / Legal Guardian's Name Address (if different from above) Work Ph. Cell Other Ph. Emergency Contact (other than parent) Name Phone Relationship Please list any facts concerning your child's medical history to which a physician, instructor, or director should be alerted: allergies, medications, physical impairments,.
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