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Rd the health, safety and welfare of the enrollees of the YCC programs and may be provided to a physician in the event treatment is necessary. This information is requested on a voluntary basis; however, failure to complete this form will result in exclusion from the program. Part I - To be completed by applicant 1. Name (Last, First, Middle Initial) 2. Address (Street, City, State, including Zip Code) 3. Do you have health and accident insurance? Yes No If yes, list name of insurer in block 4.

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