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SALEM INTERNATIONAL UNIVERSITY ATHLETIC PARTICIPATION PHYSICAL EXAM NAME DATE OF BIRTH / / AGE SS# SPORT(s) HOME ADDRESS CITY STATE ZIP EMERGENCY CONTACT RELATIONSHIP EMERGENCY TELEPHONE #(Home) ()

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Explain yes answers below are responses provided to further elaborate on affirmative responses given to specific questions.

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Individuals or entities who are requested to provide further explanation or details for their affirmative answers on a form.

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