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O. 202 Home Phone 19139 14 S 51ST ST School No. 04-29-1992 Enter Child's Social Security No. 215-747-1038 Yes Does your child have health insurance? If Yes, check the appropriate health insurance below: Name of child's doctor/clinic Phone No. Name of child's dentist/clinic Phone No. First Emergency Contact (full name) Parent/Guardian Relationship to child Aetna/US Health Care Health Partners Keystone Mercy Other Daytime Phone No Blue Cross Americhoice Keystone Health Plan East .

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