Date of Birth: 
Monday, 1 October, 0063
Other information: 
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Gender: 
Boy
School: 
34
Emergency Contact: 
85
Emergency Contact Phone Number: 
76
Parent / Guardian: 
Conny
14
53
47
Relationship of Emergency Contact to the Child: 
63
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: 
Frances