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Get General Information: - Millikin

(Please Print) Student Permanent Graduate Apt. Fall Spring Millikin ID# Mailing address: City State Zip Code Date of Birth: Gender M Student email address: Home Phone # : F Cell # : STATEMENT OF AUTHORIZATION I authorize Millikin University Health Services to administer medical and surgical services (including immunizations and allergy injections), to perform emergency procedures, and/or defer treatment to a local physician or hospital if deemed necessary.

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