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Child Full Name:_____________________________________ Date of Birth:__________

Address:___________________________________________________________________

Home Phone #______________________________________________________________

Mom Name:__________________________  Dad Name:___________________________

Cell Phone/Pager#_____ _______________ Cell Phone/Pager#____________________

Mom Work #__________________________ Dad Work #__________________________

Doctor:___________________________________________________________________

Doctor Phone #___________________________________________________________

Allergies:_________________________________________________________________

Emergency Contact:                                       Phone #