Block Island Club - Health Form and Waiver of Liability for Minors
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Minor's Name (1) *
First and last name
Minor's Date of Birth (1)
*
MM
/
DD
/
YYYY
Most Recent Tetanus Booster: Minor (1)
*
MM
/
DD
/
YYYY
Minor's Name (2)
First and last name
Minor's Date of Birth (2)
MM
/
DD
/
YYYY
Most Recent Tetanus Booster: Minor (2)
MM
/
DD
/
YYYY
Minor's Name (3)
First and last name
Minor's Date of Birth (3)
MM
/
DD
/
YYYY
Most Recent Tetanus Booster: Minor (3)
MM
/
DD
/
YYYY
Minor's Name (4)
First and last name
Minor's Date of Birth (4)
MM
/
DD
/
YYYY
Most Recent Tetanus Booster: Minor (4)
MM
/
DD
/
YYYY
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