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Please print carefully and legibly Student Name Age Grade Division School Home Address Phone Number Parent/Guardian Name Phone Number Allergies e.g. specific drugs certain foods insect stings hay fever Specify Reaction s to above Carries Epi pen Yes No Inhaler Medical Alert Bracelet Date of last Tetanus shot Medical/physical conditions that may affect participation in the stated program/activity e.g. recent illness or injury recent hospitalization or surgery chronic conditions phobias etc.....
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