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Educating for Life HEALTH CENTER COLLEGE HEALTH AND IMMUNIZATION REPORT 505 Prospect Avenue Buffalo New York 14201 716 829-8777 FAX 716 829-7646 PLEASE PRINT Date of Birth Semester Year of Entry Program NAME Last First Middle Name Male Female Complete ADDRESS permanent Street City State/Province Zip/Postal Code Telephone Number Country of birth SS /SIN Name and relationship of person to be notified in case of emergency Type of health insurance coverage/Name of company policy no. or nos. D...
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