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Get DHR-CDC-739 2001

Ter). Child's Name: Name child is known by: Child's birthdate: Child's home address: Name(s) of parent(s)/guardian(s): Home telephone number: Address of parent(s)/guardian(s): Mother's employer: Employer's address: Father's employer: Employer's address: Employer's telephone number: List telephone numbers such as beeper, cellular phone, etc. Employer's telephone number: Instructions regarding how parent/guardian may be reached in an emergency: Person(s) to be contacted in an emergency .

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