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<br />AITACIIMENTB <br /> <br /> <br />County of Orange Health Care Agency <br />Chronic Disease & Injury Prevention Program <br />Bicycle Helmet Consent Form <br /> <br />Name of Bicycle Helmet Recipient <br /> <br />Address <br /> <br />City <br /> <br />Zip <br /> <br />Telephone No. <br /> <br />Name of Distributing Agency <br /> <br />To be Completed bv Certified Bicvcle Helmet Fitter <br /> <br />1. Hclmet Model <br /> <br />Size <br /> <br />Color <br /> <br />2. I provided the following item(s) and/or service to the child named on this form: <br />(Check all that apply) <br /> <br />o Free bicyclc helmet, undamaged and in good condition <br /> <br />o One-on-one bicycle helmet fitting <br /> <br />o Information card: Helmet Fitting Tips <br /> <br />The above information is true to the best of my knowledge. <br /> <br />Certified Bicycle Helmet Fitter Signature <br /> <br />Dale <br /> <br />White (Parent/Guardian) <br /> <br />Yellow (OCHCA) <br /> <br />Pink (Grantee) <br /> <br />lofl <br /> <br />AITACHMENTB <br />KK07 <br /> <br />X:\CONTRACT 2006-07\8c1eHlmtSfty-Santa Ana City-06.07.HH.doc <br />