Hea th I f r atiHea th I f r atiHea th I f r atiHea th I f r ati
Ca per a e
F (circ e e) Height Weight Age Birth Date Grade i Fa
Date f atest b sters" Teta us P i Has the appe dix bee re ved( Yes
Is the ca per sub*ect t " C vu si s Y Hay Fever Y Asth a Y...
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Hea th I f r atiHea th I f r atiHea th I f r atiHea th I f r ati
Ca per a e
F (circ e e) Height Weight Age Birth Date Grade i Fa
Date f atest b sters" Teta us P i Has the appe dix bee re ved( Yes
Is the ca per sub*ect t " C vu si s Y Hay Fever Y Asth a Y Diabetes Y
P ease ist a y f d a ergies (f d, drugs, a i a s, etc)"
Specific hea th pr b e s r dietary restricti s"
Specia eeds r c cer s"
Is the ca per u der psychiatric care( Yes (If yes, the d ct r’s sig ed per issi wi be eeded t atte d ca p)
Hea th I sura ce C pa y" P icy u ber"
E erge cy Re ease State e tE erge cy Re ease State e tE erge cy Re ease State e tE erge cy Re ease State e t
I case f e erge cy, I u dersta d that every eff rt wi be ade t c tact e.
H wever, if I ca t be reached, I hereby give per issi t the
physicia se ected by Ca y view t h spita i3e, secure pr per treat e t f r, a d t rder i *ecti , a esthesia, r surgery f r y chi d a ed ab ve.
I, theref re, sig y sig ature"
Pare t 4ega Guardia Date
Please check week at
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