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H~J~DtCAPPED ~HILP AREA <br />~A.R~ING $IG~ R~GISTEATION <br /> <br /> (?~ e~se print) <br />ADDRESS <br /> <br />HOME PHOltE <br /> <br />Discription of Child's Handicap, <br /> <br />/ <br /> <br />WORK PHONE <br /> <br /> I <br /> <br /> I <br /> I <br />I <br /> <br />I <br /> <br />No_ re- <br /> <br />Upon request, the registrant shall provide the City' with a medical <br />confirmation of the Child's handicap. <br /> <br />l, the.undersigned parent or legal guardian of the above named handicapped <br />child, do understand that the subject signs may not provide an increased <br />level of protection or safety; and that we must not reduce the level of <br />arrant'ion we pay to our children when they are outside. <br /> <br />Signature Date <br /> <br />~d~ I <br /> <br /> <br />