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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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* Indicates required question
Your Full Legal Name
*
Your answer
Your Home Address
*
Your answer
Your Date of Birth
*
MM
/
DD
/
YYYY
First Emergency Contact (Name, Relationship, Phone Number)
*
Your answer
Second Emergency Contact (Name, Relationship, Phone Number)
*
Your answer
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