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Get HI Form 14 2002

Ddle: Entry Date Month Day Parent’s Name Year High: (Mother/Guardian) Entry Date Student Address Label / / / / (Father/Guardian) Please complete the following sections (CHECK IF YES) MEDICAL STATUS ❑ ❑ ❑ Allergy (type) Asthma Vision Problems ❑ ❑ ❑ Cancer/Leukemia Chronic Cough/Wheezing Diabetes ❑ ❑ ❑ Hearing Problems Heart Disease Hemophilia ❑ ❑ ❑ Rheumatic Heart Sickle Cell Anemia Seizures / / / / / / / / / / / Provider’s Stamp or Printe.

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