_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
__________________________________________________________________________________________________
State what efforts have been made to trace the parents or relatives and to return the child to his/her family.
_________________________________________________________________________________________________
__________________________________________________________________________________________________
Details of medical history, including immunisation
_________________________________________________________________________________________________
__________________________________________________________________________________________________
Details of education—
School _________________________________________________ Class _____________________________________
Name of supervising officer____________________________________________________________________________
Address ___________________________________________________________________________________________
___________________________________________________________
Supervisor’s signature
____________________________________________________________
Date
_____
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