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Mt. Zion House Name:___________________________________________________________________ Home Address:_____________________________________________________________ ________________________________________________________________________ Birth Date:____________________ Any Medications:___________________________________________________________ ________________________________________________________________________ Allergies:_________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Family Physician/or last Doctor:________________________________________________ Name of Medical Clinic:______________________________________________________ Address of Medical Clinic:____________________________________________________ Name of Medical Insurance Provider (If any):______________________________________ Insurance Identification number:________________________________________________ Notify in case of an Emergency:________________________________________________ Phone:_____________________________ Relationship:____________________________ The undersigned hereby accepts responsibility for all medical expenses incurred while a student in the Mt. Zion House Program. I further agree to indemnify and hold harmless Mt. Zion Christian Temple, Inc. and Mt. Zion House, their agents, members, and/or employees for any and all expenses resulting from my medical treatment. Signature____________________________________ Date:_________________________ |