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Existing Medical Conditions:

Allergies:

Photo release (checkbox):

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Written Approval

Guardian Name:

Guardian Email:

Guardian Phone number:

Guardian Relationship to Child:

Guardian Address:

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Emergency Contact Information Name:

Emergency Contact Phone:

Emergency Contact Email:

Emergency Contact Relationship to child:

Authorized pick-up list:

Pediatrician Information Doctor Name:

Pediatrician Information Doctor Phone Number:

Pediatrician Information Doctor Address:

Preferred Hospital:

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