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806-368-8983
Send me an Email
Cullen@LivingAbundantlyTX.com
Home
About Us
Mission Statement
Statement of Faith
History
About Our Executive Director
Photos
Programs
116 Ambassadors
All Star Sports Camp
HIMpact
Calendar
Sermons
Connect with Us
Contact Us
Online Giving
Online Newsletter
Volunteer Medical History
Home
Volunteer Medical History
Fieldset
Volunteer's Full Name
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Volunteer's Full Name
Address
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Street Address
Apt, Suite, Bldg. (optional)
City
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Afghanistan
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Central African Republic
Chad
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Congo
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Georgia
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Country
Phone
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Emergency Contact Information
Name of 1st Emergency Contact
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Relationship to 1st Emergency Contact
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1st Emergency Contact's Phone Number
*
Name of 2nd Emergency Contact
Relationship to 2nd Emergency Contact
2nd Emergency Contact's Phone Number
Hospital Choice
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Medical History
Allergies to medicine or foods
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Do you have any allergies to medicine or foods
Yes
No
Allergies to medicine or foods
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If you do have any allergies to medicine or foods, please list them here.
Medications and Dosage
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Medications and dosage curretly taken (including over-the-counter medication and herbal). If you are not currently taking any medication, please put NONE.
Pertinent Health Information
*
Pertinent health information that a nurse or EMS worker would need to provide better care for you. IF you do not have any pertinent health information, please put NONE
I have supplied and released the above information for use by camp nurse (or in her absence, the camp director) to other healthcare professionals (EMS, DR, ER) during an emergency during the All-Star Sports Camp.
I understand that no one will have access to this information except for the camp director and camp nurse (during an emergency).
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Date
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