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About
Get involved
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Contact
Health Form
*
Indicates required field
Name
*
First
Last
Date of Birth
*
Insurance information (Carrier and Policy Number)
*
Emergency Contact
*
First
Last
Emergency Contact phone
*
List any frequent or chronic illness
*
Dietary restrictions
*
Medications (be sure to bring extras
*
Allergies and type of reaction
*
Date of last tetanus shot
*
Any other information the leaders should know?
*
By signing below I give permission for the leadership of the East Association Churches to seek medical attention for me if I am unable to make sure a decision.
*
Today's Date
*
If team member is under 18, please have the parent or guardian sign below to authorize leaders to seek medical attention if necessary.
*
Submit
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