ࡱ>  Root EntryZ O2eB CONTENTS CompObjVSPELLING(  " " tt  (Times New Roman " " "XX*,Dhp officejet 4200 series!@d߀ odBeRLdWksWPHBeںں\\YOUR-7648F3E7A0\hp officejet 4200 series,LocalOnly,DrvConvert,winspoolhp officejet 4200 seriesUSB001F"\""V"$c"` "``""A."@"\""V"$c"` "``"."EYE EXAM ADDENDUM.wps"p"pp (" hp P * (2"'( ) @S  Z O2Quill96 Story Group Class9qFDPCSTSHSTSHyyyPSGP SGP dINK INK hBTEPPLC lBTECPLC FONTFONT<STRSPLC :PRNTWNPRlFRAMFRAM~TITLTITLDOP DOP CHNKWKS TEXTTEXT FDPPFDPPFDPCFDPCSTSHSTSHSTSHSTSH2SYIDSYIDPSGP SGP dINK INK hBTEPPLC lBTECPLC FONTFONT<STRSPLC :PRNTWNPRlFRAMFRAM~TITLTITL,DOP DOP 2BeREYE EXAM ATTACHMENT If this eye exam is being completed by a: - Physician or Optometrist and, - Are unable to sign the Ophthalmologic Exam form Then we will accept a eye exam, without dilation from the offices the exam was completed at. If faxing directly from the offices, please fax to (802) 879-7873 and include results from the eye exam, as well as this form and the Ophthalmologic form (if applicable). Signature on this form states that the recipient of this exam has good eye health, and nothing was found during this exam that would prevent him or her from fighting in the upcoming Burlington Brawl Event. ______________________________ _________________________ LICENSED PHYSICIAN S NAME (PRINT) PHYSICIAN S SIGNATURE ______________________________ _________________________ STREET ADDRESS DATE ______________________________ _________________________ CITY STATE ZIP PHONE # APPLICANT: I understand that this eye exam is only valid for the forthcoming event, and must be completed within forty-five (45) days from the event date. I further agree that a photographic copy of this agreement shall be valid as the original. ______________________________ ______________________________ DATE SIGNATURE ______________________________ ______________________________ ADDRESS NAME (PRINT) 9*(*,,.HJbhp P * (2"'( ) @S *dhp P X  "   "PS"  "PS"  ""  ""  "0"