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Box City State Zip PHONE: (home) (emergency cell) DATE OF BIRTH: THE PARTICIPANT AND HIS OR HER PARENTS MUST ANSWER THE FOLLOWING QUESTIONS AS ACCURATELY AND COMPLETELY AS POSSIBLE: Please check those that apply: (Provide necessary details below) CHRONIC AILMENTS: ALLERGIES: ASTHMA OR OTHER RESPIRATORY PROBLEMS DIABETES OR HYPOGLYCEMIA HEMOPHILIA, OR OTHER BLEEDING PROBLEMS CIRCULATORY OR HEART PROBLEMS EPILEPSY/SEIZURE OTHER MEDICATION LATEX BEE STINGS/INSECT BITES IF YES, DO YOU CARRY AN EPIPEN FOODS OTHERS, IF SIGNIFICANT DATE OF LAST Tdap (Tetanus/Diphtheria/Acellular Pertussis) SHOT: CURRENT MEDICATIONS AND DOSAGE, IF ANY: DETAILS: PLEASE MAKE SURE YOU HAVE FILLED IN ALL THE NECESSARY INFORMATION..
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