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IAC CAMPER HEALTH FORM (To be filled out by a parent and returned to our office by April 1 st.) Last Name First Name Birth Date Age at Camp Address Parent 1 Name Home Phone Cell# E-Mail Address Parent 2 Name Work Phone Home Phone Cell # Camper lives with Parent 1 Work Phone E-Mail Address Parent 2 Both EMERGENCY NOTIFICATION Name: Relationship: Phone: Name: Relationship: Phone: Physician/Pediatrician Phone: Dentist/Orthodontist Phone: MEDICAL PERMISSION STATEMEN.

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