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Is acceptable. the parents and enrolled in a recognized post- secondary institution. DECLARATION I have read the rules of the TSC medical scheme by which I agree to abide and declare that the above statements are true and complete. I consent to the Scheme Administrators seeking information from any doctor I or my dependants have consulted. SIGNATURE DATE EMPLOYER CERTIFICATION aon.com/kenya STAMP AonKenya AonKe. TSC MEDICAL SCHEME - MEMBER REGISTRATION FORM EMPLOYEE DETAILS Employee Name TSC...
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ATE OF BIRTH: Current Work Station: Cell Phone Number (if applicable): Cell Phone Type: NHIF No: Your current County of Residence: NON-DEPENDENT SPOUSE MEMBER INFORMATION NAME CHANGE CHILD MEMBER Information New Hampshire Children's Medical Center Adoptive Parents Network Contact Information Email List the first 5 of the following: Address, City, State, Zip, Telephone Number, and Fax Number Name Change Date: Date of Birth: Date of Birth of child: Last School Year: Please note that it is a requirement to include this information in the new birth certificate. Your spouse must file a new birth certificate to be adopted or to change their name. Name Change Date: Date of Birth: Date of Birth of child: Your spouse must file a new birth certificate to be adopted or to change their name. Name Change (Newborn and Newborn with Transitional Names) Date: Date of Birth: Name Change (Adopted and Adoptive) Date: Date of Birth: Name Change (Dorothy and Katheryn) (Adopted) Date: Current Employer: CHILDREN'S CARE FAMILY MEMBER INFORMATION Information Name Change CHILD Care Family Member New Hampshire Children's Medical Center Adoptive Parents Network Contact Information Email List the first 5 of the following: Age, Place of Birth, City, State, Zip, Telephone Number, and Fax Number Child Care Family Member Age: Race: Ethnicity or National Origin: Birth Month: Birth Year: Father's First Given Name: Name of Father: Date of Birth: Father's Last Name: Mother's First Given Name: Mother's Full Name: Mother's Middle Name: Date of Birth: Mother's Last Name: Brother/Sister Birth Month: Brother/Sister Age: Birth Year: Sister's First Given Name: Sister's Full Name: Sister's Middle Name: Name of Brother/Sister: Last School Year: Your Age: Adoptive/Supportive Parents/Guardians in NH- Adoptive Parent Information (If adopting a child whose first name is currently unknown) Name: Supportive Parent Information (You may be able to nominate parents if you know them/have met them) Name: Dorothy's Children's Medical Center Adoptive Parents Network Contact Information Email List the first 5 of the following: Age, Place of Birth, City, State, Zip, Telephone Number, and Fax Number Birth Day/
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