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VBC Wayland
VILLAGE BAPTIST CHURCH
Health declaration
Please fill out the following form.
First name
Last name
Email
*
Date of birth
Month
Month
Day
Year
Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness or injury?
No
Yes
Please list any allergies
Please list any medications, times and amounts of dosage
If you answered yes to any of the questions above, please supply additional information.
Initials
*
I declare that the info I’ve provided is accurate and complete.
*
Submit
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