Love is King Operation Roam Treatment Authorization Form
This form grants temporary authority to the expedition medical personnel and to the expedition
leader to provide and arrange for medical care in the event of an emergency.
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Your Full Legal Name *
Your Home Address *
Your Date of Birth *
MM
/
DD
/
YYYY
First Emergency Contact (Name, Relationship, Phone Number) *
Second Emergency Contact (Name, Relationship, Phone Number) *
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