Date of Birth: 
Thursday, 14 August, 0092
Other information: 
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Gender: 
Boy
School: 
32
Emergency Contact: 
57
Emergency Contact Phone Number: 
69
Parent / Guardian: 
Imelda
56
29
10
Relationship of Emergency Contact to the Child: 
64
School Year: 
11
I agree that my child may receive emergency medical treatment by a trained member of staff or medical practitioner if needed: 
Doctor Address: 
Minerva