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					CCBC Member ID Tag Form

The front view shows name, city and state. The reverse view allows optional space to add emergency
information. Complete application and send to address shown below. Please carefully proofread application
before sending and also the personalized tag when you receive it.

PRINT CLEARLY AND LEGIBLY:

Front View:

FIRST NAME:

LAST NAME:

CITY:


Back View: (each line item optional)

Name and complete address/phone #:


Emergency Contact name/phone #:


MD's name/phone #:
Blood Type:
Special Medications:
Allergies:


Special Health Info:




Signature:
Date of this Application:


                               Send with self-addressed, stamped envelope to—

                                                  Don Kennedy
                                             2158 Calusa Lakes Blvd
                                               Nokomis, FL 34275

                            Questions: Don Kennedy, 941.483.4807, donken60@gmail.com




Edited Jan. 14, 2011. sge