Preschool Application

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Person(s) to contact in case of Emergency / Authorized to pick up child:

Names of Children in family:

Child's Health History

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Check an of the following illnesses the child has had:

I authorize the child care provider/staff to obtain the following services for this child if necessary: Public Health Nurse, Physician and or Ambulance in the event of an emergency. (Ambulance fees and/or health care costs are the responsibility of the parent/guardian.)
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