S, indicate: (07) HOSPITAL PREFERENCE . 0 Medicaid airivate 0 Healthy Kids/Kid Cam 0 Interested in receiving information eittiS •i p ER, tpl.PeEtliii,„_, ,,,,,_ cfrk oil _ ,§q. ,pp 73, (49) NAME OF CHILD (fast k( mktile MN) SCHOOL ATTENDING STUDENT NO. (opOona9 GRADE DATE OF BIRTH (50) NAME