B UT ME
MAGAZINE INK
Medical Information Form This information is not required. We have no interest in your personal background. This is on a voluntary basis, so, that we may determine if you have any special needs so that we may serve you properly.
Please print DIVISION: TITLE: NAME: ADDRESS: CITY: STATE: POSTAL CODE: COUNTRY: REQUIRED INFORMATION: Contact in case of emergency? Name / Relationship: Telephone Number: Please list allergies: OPTIONAL INFORMATION: Current Illnesses: Current Medications: Special Dietary Needs: Other Special Needs: ___________________________________________ __________________________________ ENTRANT'S SIGNATURE DATE _________________________________ __________________________________ LEGAL GUARDIAN (if under 18) DATE
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