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RITY NUMBER SCHOOL PHYSICIAN TELEPHONE ( PHYSICIAN'S ADDRESS (street and number) - PARENT/LEGAL GUARDIAN (city) ) EXTENSION (state) (zip code) Diagnosis History and background of medical condition Describe any limitations placed on school activities How will this condition affect attendance in school? Will the school requested ameliorate the health condition? Yes SIGNATURE OF PHYSICIAN PBSD 1893 (Rev. 4/11/2011) No If Yes, how? DATE.

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