3515B: Food Allergy Background

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Full Name (at time of attendance)

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Birthdate

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Does your transcript need to be sent to a 3rd party? (to a college, university, employer, etc.?)

If yes, where?

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Please initial below to acknowledge that you are the student named above and that you have reviewed the information above and agree that it is accurate. By initialing below you endorse this document as legally binding in accordance with the e-sign bill S.761 and release the below initials in lieu of a signature.

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