Emergency Contact & Medical

Participant

Cast / Crew Member

Production / Show

Date *

Full Name *

Cell Phone *

Email *

Confirm Email *

Address *

If under 18

Participant is under 18 (parent/guardian info required)

Contacts

List people we may call if we cannot reach the participant or parent.

Primary contact

Name *

Phone *

Relationship *

Secondary contact (optional)

Name

Phone

Relationship

Medical

Allergies

Medical conditions / medications

Special instructions

OTC permissions

Acetaminophen (Tylenol) Ibuprofen (Motrin) Diphenhydramine (Benadryl) Neosporin None of these

Youth pick-up

People other than the parent/guardian who may pick up a youth participant.

Name

Relationship

Name

Relationship

Parent / guardian signature (if under 18)

Sign above