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Get Off-campus Event Emergency Information Form - California State ...

P Address Home Phone # Work Phone # Address Home Phone # Work Phone # Personal Physician s Name Address Phone# I am presently under the following medication I am allergic to the following medication Presently wear contact lenses? Presently wear glasses? Please state any medical conditions that emergency care providers need to be aware of Do you have health insurance? Name of Insured (if different from self) Name of Company Policy # Relationship Telephone # Address of Company If I n.

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