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PARENT PERMISSION FORM Student’s Name BURNS HIGH SCHOOL HEALTH CENTER (ph[removed]Grade _______
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Document Date: 2011-09-29 11:41:27

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Facility

PLEASE NOTIFY HEALTH CENTER OF ANY CHANGES / /

IndustryTerm

certain confidential health services / federal law / expanded health services / mental health services / health services / insurance card / confidential services / student services / /

MedicalCondition

sexually transmitted disease / /

Organization

PARENT PERMISSION FORM Student’s Name BURNS HIGH SCHOOL HEALTH CENTER / Health Center / School Health Center / U.S. Securities and Exchange Commission / PLEASE NOTIFY HEALTH CENTER / School Based Health Center / Cleveland County Health Department / /

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Position

General / NC General / Physician Assistant / Nurse / /

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