NAUVOO RETREAT Registration Form for Ages 12-18, March 27-29, 2020

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* 1. Please share the following information:

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* 2. Please provide the following health insurance information in case of a health care situation: (Information will be kept confidential)

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* 3. List any special conditions such as bed wetting, fainting, sleep walking, or allergies participant has:

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* 4. List any health, behavioral or emotional problems participant has, including current infectious diseases:

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* 5. List any medications participants takes: (Include name, frequency & dosage for each one:

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* 6. Date of last Tetanus Shot: (Month/Year)

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* 7. List any activities child cannot participate in:

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* 8. By checking "YES" below you and your child verify that you have discussed the activity restrictions with them and he/she understands them and agrees to abide by them, or check "NA" if there are NO restrictions:

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