| Document Date: 2014-04-29 11:18:07
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City Boston / / Company Health Insurance Co. / / MedicalCondition Immune System Disorder Kidney Disorder Frequent Urination Cancer / last Tetanus / Intestinal Problems Recurrent Diarrhea Gallbladder Problems/Surgery Dizziness/Fainting / Medications Food Allergies Other Allergies / R/L Arthritis Joint Disease / Breath Chronic Cough Tuberculosis Head injury w/ unconsciousness Allergy / / MedicalTreatment first aid / Surgery / Appendectomy / / MusicGroup Niagara / Trip / / NaturalFeature Boston/ Niagara Falls / / Person Becky Hercula / Warren Mott / / Position Breath Chronic Cough Tuberculosis Head / / Technology cellular telephone / / |
WARREN MOTT HIGH SCHOOL BAND Student Health Authorization Form – Boston/ Niagara Falls trip Dear Parents: Under certain conditions as a service to you and for the welfare of your child, Warren Mott Band personnel may a