Annual Health And Medical Record Part CAnnual Health And Medical Record Part CAnnual Health And Medical Record Part C
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Parte A Nombre completo

Fecha de nacimiento Alergias

Teléfono en caso de emergencia

Part A Full name:_________________________________ DOB:________________ Allergies:___________________ Emergency contact No.:______________

Annual Health and Medical Record
Registro Médico y de Salud Anual
Part A/Parte A

High-adventure base participants:
Participantes en la base de aventura extrema:
Expedition/crew No.
Expedición/grupo no.:_______________________________
or staff position
o puesto fijo: ______________________________________

GENERAL INFORMATION/INFORMACIÓN GENERAL

Name ____________________________________________________ Date of birth ___________________________________ Age ____________
Nombre

Fecha de nacimiento

(MM/DD/Year) - (MM/DD/Año) Edad

Male

Masculino

Female

Femenino

Address ______________________________________________________________________________________________ Grade completed (youth only)______________________
Domicilio

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