| Document Date: 2013-12-17 17:54:37
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IndustryTerm food / / MedicalCondition Hernia / paralysis / Headaches/Migraines / allergies / Sleep walking / seizures / diarrhea / Bronchitis / constipation / nausea / behavior disorders / Have Had Yes No Colds/Sore throat / Cramps / anaphylaxis / Diabetes / disorders / i.e. hives / Asthma / / MedicalTreatment first aid / / Organization Mount Olive Church / Lutheran Church Youth Ministry / / Person Olive Youth / Olive Church / / Position physician / surgeon / HEREBY AUTHORIZE THE ADULT LEADER / dentist / / Product Tylenol / Benadryl / Polysporin / Ibuprofen / Hydrocortisone / / ProvinceOrState California / / Technology x-ray / /
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Medical Release Form Mount Olive Lutheran Church Youth Ministry 1989 East Calaveras Blvd. Milpitas, CA[removed]0506 Name:_________________________________________________________________________________ Last