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History Authorization 2014-2023
Only
Father Only
Other:
Address (if different than child’s):
Phone 1:
Phone 2:
Phone 3:
Parent/Guardian 2:
E-mail:
Address (if different than child’s):
Phone 1:
Phone 2:
Phone 3:
E-mail:
EMERGENCY CONTACTS
Name:
Relationship:
Phone 1:
Phone 2:
Phone 3:
Name:
Relationship:
Phone 1:
Phone 2:
Phone 3:
HEALTH INFORMATION (Check all that apply and provide requested information)
Allergies
Yes
No
Explain “yes” answers. Include the type of allergy (e.g.- “nut allergy” in the...
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