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Ation that took place more than twelve (12) months prior to departure for Israel and that AMHSI will refuse admission to the student in such case. In the event that the examination has occurred more than sixty (60) days prior to departure, but less than twelve (12) months, an affidavit written and signed by the physician must accompany the physician’s medical questionnaire stating that no changes in the Student’s physical/psychological/medical history has occurred. PLEASE COMPLETE THIS FORM .

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