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Health Form


Health & Additional Registration Information
First Name
Last Name
Birthdate (MM/DD/YYYY)
Address
Roommate Request
Pre-Existing Medical Conditions
Current Medications
Wears Glasses/Contacts
Major Illnesses in last year
Date Last Tetanus shot/booster
Any activity restrictions
Insurance Carrier
Policy Carrier Name
ID #
Group #
Phone # on card
Photo of Insurance Card
Emergency Medical Authorization
Liability Release
Insurance Card Photo
Diet & Allergies
Alcia
Browne-Weston
08.19.1975
Jennings Village St.Mary's Parish Antigua
​
​
Cresta, metoprolol
No
​
​
Nagicor
Alcia Browne-Weston
268043831
​
1-268-779-6244
​
Aniyah
Walcottt
​
​
​
​
​
​
​
​
​
​
​
​
​
diet: pescetarian
Christian
Wolf
07/26/2006
205 Andover Ln., Lititz, PA, United States of America, 17543
​
Frequent Bloody Noses
No
pneumonia
9 years ago
no
Eliance / Cingna
Liesl Wolf
EHS04938W83058
EH00094
717-560-9290
​
Clara
Samuels
​
​
​
​
​
​
​
​
​
​
​
​
​
diet: vegetarian
Clint
Baynes
11/05/1975
3-5 NUGFW Housing development Lopinot road Arouca
No
No
No
No
2022
No
Guardian Group Insurance
Clint Baynes
N/A
N/A
N/A
​
Dan
Miller
​
​
​
​
​
​
​
​
​
​
​
​
​
diet: vegetarian
Donnecia
Joseph
01072009
Old Road Village
​
None
None
No
​
No
Nagico Insurances
Geo W Bennett Bryson & Co. LTD
268043822
ANGLH005/10
13058228430
​
Hilda
Cieza-Regalado
08/05/2006
271 N Hawthorne Rd, Winston-Salem, NC 27104
n/a
n/a
n/a
n/a
01/03/2022
n/a
A UnitedHealthcare Company (UMR)
Ruben J Cieza Hernandez
44154562
76-416339
877-233-1800
​
Iyani
Mercer
08/04/2010
P O Box 304688, St Thomas, VI 00803
​
no
no
no
​
none
Cigna
Innocent Liburd
U37127017 03
3327595
800-579-0613
​
Joanna
Genemans
11/08/2006
11241 Angleberger Road, Thurmont, MD, United States, 21788
​
No
Vestura, Aller-tec
No
2018
No
BlueCross BlueShield
Jan Genemans
LAM839002628
000LAM1902474
1-800-348-6515 Ext. 12
allergies: macadamia nuts, shellfish diet: pescatarian
Jonathan
McPherson
08/30/2010
​
​
No
No
No
2017
No
Sagicor Health
​
6860000278-03
46860-00001
876-929-8930
​
Jonathan
McPherson
08/30/2010
(Florida International University) 1590 SW 111th Ave. Miami, FL 33199
​
No
No
None
​
None
Sagicor Health
Clive McPherson
6860000278-04
46860-00001
8769298920
​
Keshana
Bartlett
06/14/2006
#33B Husbands New Development, St. Michael, Barbados, BB23032
​
Asthma
​
No
05/05/2017
No
icbl
Kevin Hinds
020451800085
​
+1 (246) 434-6000
​
Leah
Turnbull
​
​
​
​
​
​
​
​
​
​
​
​
​
allergies: amoxycilin
Marcasia
Dixon
05/05/2009
Huntley District, Huntley P.A Manchester, Jamaica WI
Nyla Whyte and Aleisha Farquharson
No
No
No
2014
No
​
​
​
​
​
diet: does not eat pork or peanut butter (but not allergic to either)
Megan
Vanderbloemen
12/14/2002
1891 Montana Avenue
​
​
​
N/A
3/10/2014
​
Quartz
Laurie Vanderbloemen
71302930903
9001123
800-362-3310
​
Michelle
Flemming-Daley
06/05/1980
Burbank, Kingston 19
​
High Blood Pressure
Amlo Dena
No
​
No
Sagicor
Michelle Flemming-Daley
0008959444-00
910000-04971
8769298920-9
​
Miles
Clore
03/28/2010
4528 Jasper Ridge Drive, Clemmons, NC, USA, 27012
​
ADHD
Vyvanse 70mg - 1 daily in the morning; Zoloft 50mg - 1 daily at bedtime; Miralax - 1 capful in 12 oz apple juice at dinner
Pneumonia - onset Aug 30, 2024
10-07-2021
No
Aetna
David Clore
NU2AQKAJXNCK
0192685
1-833-690-1037
​
Naeem
Baynes
08/25/2007
3-5 NUGFW Housing development Lopinot road Arouca
No
No
No
No
2021
No
Guardian Group Insurance limited
Clint Baynes
N/A
N/A
N/A
allergies: peanuts
Riddick
Weber
04/05/1965
2535 Hampshire Rd, Bethlehem, PA, 18017
​
no
Atorvastatin
No
Not sure
No
Capital Blue Cross
Charles R Weber
YWP80252135100
00531833
800 216-9741
​
Rihanna
Roberts
02/28/2009
Antigua
Donnecia
No
No
No
12/17/2024
No
Medicare
​
​
​
​
​
Sayuri
Blake
08/26/2009
7 Reef Avenue, Harbour View, St. Andrew, Jamaica
​
No
No
No
N/A
No
N/A
N/A
N/A
N/A
N/A
​
Sylvia
Hauser
09/14/1996
1320 Utah St. Sturgeon Bay, WI 54235
​
No
No
No
I’m up to date
No
BlueShield
Sylvia Hauser
RIR135066382001
RIR378
18668230924
​
Taniel
James
​
​
​
​
​
​
​
​
​
​
​
​
​
allergies: peanuts, ground nuts, whole milk, eggs, strawberries, pineapple, ketchup, cheese
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