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State/territory in which child resides 2. Is this child exempt from any immunizations YES List them OR 1. Country in which child resides 2. Attach Department form DHMH-896 record of vaccination or immunity Date DHMH-4768 1/15 Once the form has been filled out please send all forms to campforms gcconline. CAMPER HEALTH HISTORY Child s Name The following information is required 1st Emergency Contact Parent or Legal Guardian Phone 2nd Emergency Contact Other than Parent Above Child s Physician...
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