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* 1. Child Information

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* 2. Parent #1

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* 3. Parent #2

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* 4. Emergency Contact (when parent above can not be reached)

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* 5. Emergency Contact #2 (when parent above can not be reached)

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* 6. Written permission must be on file for anyone other than a parent/guardian listed above to pick up your child from the center. Please list below the legal name as shown on a valid ID of any person allowed to pick-up your child:

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* 7. Medical Information

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* 8. Legal Information

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* 9. Please sign your full name in the box below if you give consent for your child to receive first aid by staff and, if necessary, be transported to receive emergency care. By signing you understand that you will be responsible for all charged not covered by insurance, and note that you agree to review and update this information whenever a change occurs and at least once a year as per our centers licensing requirements.

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