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EFTA01710219
may we have you• permission to call your doctor or emergency services (911) for transport to the hospital? RYES O NO Ye) PHYSICIAN PfCtE ERI.R:NEPMN.:?. TaVAS U1/4)gi *E- :MEM/WARMAN: (49) NAME CF CHILD (Mg ant Mildkrintiel) SCNOCI. ATTEIONG STUDENT NO. (GlAbsIG GRADE DATE OF BIRTH (50) NAM
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