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NYC 2022 Health Form
DUE ASAP
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* Indicates required question
Email
*
Your email
Please fill out the following so we can have a general background of your health, in case of emergency at National Youth Conference 2022.
Thank you!
First Name
*
Participant First Name
Your answer
Middle Initial
*
Participant Middle Initial
Your answer
Last Name
*
Participant Last Name
Your answer
Date of Birth
*
Participant Date of Birth
MM
/
DD
/
YYYY
Sex
*
Female
Male
Address
*
Street
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Parent/Guardian
First and Last Name (youth participants only)
Your answer
Parent/Guardian Cell Phone
Cell Phone # of Parent/Guardian (if applicable) xxx-xxx-xxxx
Your answer
Parent/Guardian Address (if different than above and if applicable)
Street
Your answer
Parent/Guardian City
Your answer
Parent/Guardian State
Your answer
Parent/Guardian Zip Code
Your answer
Emergency Contact Person
*
First and Last Name (Different than parent/guardian)
Your answer
Relationship
*
to participant
Your answer
Emergency Contact Cell Phone
*
xxx-xxx-xxxx
Your answer
Insurance
Is the participant covered by family medical/hospital insurance?
*
Yes
No
Carrier/Plan Name
If covered
Your answer
Group Number
If covered
Your answer
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