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Waiver Form

Res Academy Health Waiver

To register for on of our programs please fill out the following medical form.

First Name

Email Address

Last Name

Date of Birth

Emergency Contact

Are there are allergies or injuries that we need to be aware of? *

No

Yes

Have you lost your consciousness in the last past 12 months? *

No

Yes

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Thanks for subscribing!

E-mail: reshopefoundation125@gmail.com

Phone: (774)922-3336

Location: 70 James Street , Worcester, Ma 01603

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