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Emergency Contact Form

  • 1. What's your first name? *

  • 2. What's your last name, [ANS_1]?

  • 3. And your ID number? *

  • 4. In which country were you born?

  • 5. What is your blood type?

    You can give only one answer.
  • 6. Do you have any medical conditions or allergies we should know about? *

    Please also let us know what medications, if any, you are currently taking.
  • 7. Finally, what is the name of your emergency contact? *

    This person must be at least 18 years of age.
  • 8. What is [ANS_7]'s relation to you?

    You can give only one answer.
  • 9. And what is their phone number?* *

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