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Get FL DH3040-CHP 2013

A legally qualified professional. Additional requirements may be determined by local school districts. (Please Print) Name of Child (Last, First, Middle) Birth Date Sex Address (Street) School Grade City and ZIP Code Home Telephone Number Parent/Guardian (Last, First, Middle) PART I — CHILD’S MEDICAL HISTORY To Parent/Guardian: Please check answers to questions 1 through 8 below in the column on the left. (Please explain any “Yes” answers in the space provided below.) 1. Yes 2..

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