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Get and Sign Ifcb4 Cobb 2017-2022 Form
Insurance:
Name of Insured:
Policy Number:
Group Number:
Medical Information
Family Physician:
Phone:
Immunizations:
Does the student need to take medication?
Yes
No If so, what medication?
Previous operations or serious illnesses:
Special medical conditions:
Allergies?
Yes
No
If yes, please identify allergy:
Medication
Food
Stinging Insects
Please identify:
Dietary Restrictions:
Other
Release
The District does have an indemnity plan pursuant to O.C.G.A. § 20-2-1090 that may or may not...
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