1. No category


‫אישור רפואי‬
PHYSICIAN'S EXAMINATION
DATE OF TRIP
First Name –
DASTINATION
Last Name –
ID –
Birth Date –
Medical limitations
Medications taken
regularly
Allergies
Current Medical
Problems and Treatments
Recommendations
I have examined the person herein described
and have reviewed the health history. It is my
opinion that this person is physically able to
engage in camp activities, except as noted
above.
Name of Doctor
Medical Center
Date
Signature & Stamp
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