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Get and Sign Student Claim Form 2013
Child
City:
)
Date of Birth(mm/dd/yy):
Other (please explain)
ACCIDENT INFORMATION
Type of Accident:
Auto
IC Sport
Date Occurred:
Intramural Sport
Interscholastic Sport
Work
Other
Type of Sport (Football, track, etc.):
Details of Accident:
INJURY / SICKNESS INFORMATION
Have you suffered the same or a similar condition in the past?
Physician’s Name:
Yes
No If Yes, and if you were treated for it, please provide information:
Physician’s Address:
Date...
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