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Get AL ADD/ADHD Individualized Healthcare Plan 2021-2024

Gies School: Bus (check one) YES NO Bus #AM Phone # District: School Nurse: Bus #PM Cell # Medication taken at home: (please list) Contacts Mother Home # Work # Cell # Father Home # Work # Cell # Guardian/Custodian Home # Work # Cell # Home Address City # Zip Emergency Contact (Relationship) Home # Work # Physician Phone # Fax# Physician Address City Zip Date Special Notes 1 Alabama State Department of Education Individualized Health Care Plan Student Name.

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