New Member Information
The purpose of these questions are for 13thirty staff to contact you, to introduce our programs and events. We use reasonable means to maintain security of all communications, but complete confidentiality is not guaranteed. Please provide only what you feel comfortable.
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Preferred method of contact:  *
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I would be open to a visit from a 13thirty staff member at the hospital. *
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Emergency Contact
Emergency Contact Name *
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Relationship to Emergency Contact  *
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Emergency Phone Number *
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Emergency Contact Email
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