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I I Club or High School I week in gym HeightWeight of years gymnastics Current Injury and brief history of how it happened Is this a rein jury D Yes D Questionnaire Plea. Signature Date Signed Request will not be processed without the signature and ID of the applicant full fees and established eligibility If Child less than 2 yrs Name of Hospital or Midwife Division of Vital Records Phone 1000 NE 10 th Street PO B Partner Parents Other children Doula Other present before ANDOR during labor During labor Id like Music played I will provide The lights dimmed The room as quiet as possible As few interruptions as possible As few vaginal exams as possible Hospital Renewal and new applicants must answer every question 111 Complete all items on this form and have it signed by a State legislator 1 Have you ever been convicted of a crime yes no If yes enclose a statement of details 2 Have you ever been a Notary P Title Address line 1 Address line 2 Phone Email Please submit a PDF or jpeg formatted in the correct size Example Business Card with Bleed Your design should 57375ll the entire dark gray box however the area between the two boxes WILL be cut o57374 T 3: _________________________________________________________ CHILD 4: ______________________________________________________________ NAME DATE OF BIRTH ___________________________________ HEALTH COVERAGE ENROLLMENT FORM EMPLOYEE/PARTICIPANT INFORMATION SOCIAL SECURITY NUMBER CITY MALE FEMALE HOME PHONE SPOUSE INFORMATION ThMnk you in MdvMnce for requesting Mn MpplicMtion to become M citizen of the United Fherokee Ani - Yun - WiyM NMtionB Fitizenship in the United Fherokee Ani - Yun - WiyM NMtion is open to Mny perso HEALTH COVERAGE ENROLLMENT FORM EMPLOYEE/PARTICIPANT INFORMATION SOCIAL SECURITY NUMBER CITY MALE FEMALE HOME PHONE SPOUSE INFORMATION IF N Name Date of Birth// Place of Birth Sex Male Female Language Spoken at Home Name of Mother Address Name of Father Address Occupation of Mother Occupation of Father FAMILY HISTORY Please attach a copy of vaccination recordsChilds NameDate of Birth Gender M/F Ethnicity Mothers Name Fathers Name Siblings Names and birthdates Facility name and location of childs birth Birth weight Name Age Referring PhysicianOther physicians you have seen include location Current Height Current Weight PAST HISTORY Please list all of your health problems such as asthma diabetes heart disease hig ----------------------------- about live birth characteristic in the every . country. 1—date of occurrence . . yes. 2—Date of registration . . APPLICA DA BIR TH IN SCHOOL RECORDS TIFICA TE OF QUALIFICA I) G.O(Rt) No. 853/2011/G.Edn. (G) Dt. 1.03.2011 (GEdn.) Dept. II) G.O. (Rt)No. 2281/2011/G. Edn. Dt. 18.06.11G.Edn. (G) Dept(To be r