EMERGENCY MEDICAL FORM

 

PARTICIPANT INFORMATION

Name:                                                                                                           Birthdate:                                                                                    Age:                         

Address:                                                                                       City:                                                           State:                                         Zip:                          

Home Phone:                                                                               Cell #1:___________________________  Cell #2: ________________________

Email:  _______________________________________________

Father’s Name:                                                                                                            Work #:                                                                      

Mother’s Name:                                                                                                          Work #:                                                                      

Other Emergency Names & Phone #s:                                                                                                                                                                                      

Family Doctor:                                                                                                            Office Phone:                                                                                             

Name of Family’s Medical Ins. Co.:                                                                                                                                                                                          

Ins. Provider’s #:                                                      Plan #:                                                        Provider’s #:                                                                             

 

CONFIDENTIAL HEALTH HISTORY

Does the above participant have any conditions or take any medications that may affect participation in Stage Wright Theatre activities?                 1Yes      1No      

Explain:                                                                                                                                                                                                                              

 

PERMISSION FOR EMERGENCY MEDICAL TREATMENT

In the event my son/daughter becomes ill or sustains injury while in the care or under the supervision of Stage Wright Theatre or its leaders, consent is given to admit him/her to any hospital facility and for all medical, surgical, diagnostic and hospital procedures for him or her when such treatment is deemed immediately necessary or advisable to safeguard my son/daughter and it is not advisable or possible to return him/her to me or receive my instruction for his/her care.  I waive my right to inform consent for said treatment.

 

Date:                                                                                                              Parent Signature: