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Nome_________________Cognome__________________

Nato
il___________________________a______________________________
Residente a
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Tel.
abitazione__________________________________________________
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Tel. del padre:
cellulare________________________lavoro______________________
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Tel. della madre:
cellulare________________________lavoro______________________
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Tel. nonni paterni________________________
Tel. Nonni materni_______________________
Altri___________________________________
Eventuali intolleranze e/o
allergie______________________________________________________
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Note su eventuali problemi sanitari (necessit di farmaco salvavita)
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