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Membership Form
Please fill out the Comfort Quarters LLC membership form below
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Last name
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Address
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Birthday
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Marital Status
Legal Guardian
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Legal Guardian Email
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Legal Guardian Phone Number
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Legal Status
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Primary Insurance
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Health Insurance Benefits and Policy Number
Gender
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Gender Preference of Roommate
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Surgical History
Statement of Primary or Secondary Disablility
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Medical Conditions/Diagnoses. Please List All:
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Current Medication
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Signature
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