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This authorization is NOT TO EXCEED 1 YEAR. 12a. FROM 13. PRESCRIBER S NAME/TITLE TELEPHONE 12b. TO This space may be used for the Prescriber s Address Stamp FAX 14a. PRESCRIBER S SIGNATURE Parent/guardian cannot sign here 14b. CAMP INFORMATION CAMP NAME ADDRESS CITY STATE ZIPCODE II. PRESCRIBER S AUTHORIZATION 1. CHILD S NAME 2. KNOWN SIDE EFFECTS SPECIFIC TO CHILD 12. MEDICATION SHALL BE ADMINISTERED during the year in which this form is dated in 14b below unless more restrictive dates are...
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