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Passed out/had chest pain during exercise. Had mononucleosis mono during the past 12 months. If female have problems with periods/menstruation. I understand the information on this form will be shared on a need to know basis with Crystalaire Inc Camp Lookout staff. I give permission to photocopy this form. In addition Crystalaire Inc Camp Lookout has permission to obtain a copy of my child s health record from providers who treat my child and these providers may talk with the program s staff...
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