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2180 Iowa Avenue Riverside CA 92507 (951)787-6754 www.habitatriverside.org Volunteer Agreement Release from Liability Form Name (individual) / Group: Group: Individual: (Mark one) Group Code: (office use only) Volunteer Address: City: State: Zip: Phone: () Email address: 1.. The information below is needed by any hospital or medical practitioner not having access to the volunteer s medical history: Allergies (medicines, food, etc): Blood Type: Date of last tetanus shot: // Medications currently taking: Have you had any injuries, surgeries or illnesses in the past 6 months If yes, please list: Personal Physician (Name): Phone: () Address: City: State: Zip: Health Insurance Coverage Company:
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