| Name | O daqvov u Franz |
|---|---|
| Date of Birth | 02/06/1960 |
| Address | 4874 Norman Street Xpcf a tklayf Long Beach, Gl y n u 90802 United States Map It |
| Home Phone | (323) 287-4273 |
| Mobile Phone | (323) 287-4273 |
| Email hidden; Javascript is required. | |
| I am a competent swimmer | Yes |
| In Case of Emergency | Please provide an Emergency Contact |
| Name | R fv alou qmmh Franz |
| Home Phone | (323) 287-4273 |
| Mobile Phone | (323) 287-4273 |
| Email hidden; Javascript is required. | |
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| Health History | The following information is requested. This information will be kept confidential and shared only when as deemed needed. Any changes to this information must be provided to the boat captain. Please provide complete information, so that we can be aware of your needs. |
| COVID-19 Vaccine | Yes |
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| Medications Being Taken | NO, Medications on a routine basis. |
| Do you have a history of Asthma? | Yes |
| Do you have a history of seizures? | Yes |
| Are you Diabetic? | Yes |
| Do you have abnormal blood pressure or a history of heart disease? | Yes |
| Have you ever had an anaphylactic reaction? | Yes |
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| Food Preferences | Please check those you like & add comments where necessary |
| Food Likes |
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| Breakfast | Hearty |
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| Bar Preferences |
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