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MEDICAL CERTIFICATE Chabad Kiddie Camp DAY CAMP 2016 5776 201-907-0686 Camper s Name Date of Birth Parent s Name Insurance Carrier Holder s Name Group Name and Number ID Number Immunization History Please attach a copy of your child s immunization record Diphtheria Hepatitis A Tetanus Hepatitis B Current Medications Polio HIB Measles Influenza Pertussis Pneumococcal Mumps Varicella Name Dosage Reason Rubella Medical History Date Other Medical Information Is/has you child being/been treated...
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