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er II I - American Indlan/Alaslcan Native D B - Black, Non-Hispanic 0 H - Hispanic 0 W - White, Non-H
nt have any allergies? (if yes specify) f'Yes 0 No Allergy 1 18. Physician Name 1 J c•12,n APIA. 01/4.A Telephone Number Parental Consent for Release of Student Information I hereby give permission for the school or District to use my chikfs photograph, video Image, writing, voice recording, name, grade level, school n
nder O i - American Indian/Alaskan Native O B - Black Non-Hispanic O H - Hispanic O W - Whke, Non-His
dents illnesses, behavior issues, medications or physical limitations. student will use. 18. Physician Name Telephone Number Parental Consent for Release of Student Information I hereby give permission for the school or District to use my chid's photograph, video image, varkig, voice recording, name, grade level, school na
er II I - American IndlaniAlaslcan Native D B - Black, Non-Hispanic 0 H - Hispanic 0 iiv - White. Non
student have any allergies? (if yes specify) 'Yes CI No Allergy 1 18. Physician Name 1 J ce-4., inn tc,k Telephone Number Parental Consent for Release of Student Information I hereby give permission for the school or District to use my chikfs photograph, video Image, writing, voice recording, name, grade level, school n
Entities connected to both Leon Black and Release of Student Information

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