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Get Eastern Connecticut State University Athletic Pre-Participation Evaluation 2011

Please answer the questions below BEFORE taking this form to your doctor’s appointment for your physical. Your health care provider must complete the second page of this form. RETURN FORM TO: ECSU Student Health Services, 185 Birch St., Willimantic, CT 06226, or Fax to: 860-465-4560. IMPORTANT: Please make sure to read the notice and information on sickle cell trait included with this form. Name: ____________________________ Sport: _________________________ ID No. __________________________.

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