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Get VA HPE-h12 2010-2024

Middle Initial Parent/Guardian_______________________________________________________ Phone#:(work)______________________________ Last First Middle Initial (home)______________________________ (cell)________________________________ Please provide information relative to the general health of your child entering school for the first time. ACUTE or CHRONIC ILLNESSES: Asthma Yes____ Cerebral Palsy Yes____ Cystic Fibrosis Yes____ Diabetic ( dependent) Yes____ Epilepsy Yes____ Frequent Colds.

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