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First Name
Last Name
Mobile
Shenasname Code
National Code
Address
Postal Code
Birthdate
Sheba Number without IR
Father's Name
Father's National Code
Father's Birthdate
Father's Mobile
Father's Job
Mother's Name
Mother's Family Name
Mother's National Code
Mother's Birthdate
Mother's Mobile
Mother's Job
Emergency Mobile (1)
Emergency Mobile (2)
Does your child require special medical care in the following areas?
Yes
No
Thalassemia
Hemophilia
Severe Anemia
Diabetes
Kidney Failure
Cardiac
Asthma
Leukemia
Goiter
Allergy
Spinal Deformities
Mobility Problems
Hearing Impairment
Lazy Eye
Vision Problems
Does the child take any specific medications regularly?
Yes
No
If yes, what medication?
Does your child have any specific food or other allergies?
Yes
No
Food allergies include
Other allergies
Does your child have a history of seizures?
Yes
No
History of severe fevers
Yes
No
Does your child have a history of surgical procedures?
Yes
No
If yes, what procedure?
Has your child ever experienced fractures or broken bones?
Yes
No
Which body part?
Has your child been in kindergarten before?
Yes
No
Kindergarten name
Kid's image
Image of the first page of the kid's birth certificate
Photo of the first page of fatehr's identity certificate
Photo of the first page of mother's identity certificate
برای تغییر کد امنیتی، روی عکس بالا کلیک کنید