Performer Medical Disclosure & Emergency Contact Form

This form is for Stage Management use and the information provided by you is strictly confidential.

Name

First Name

Last Name

Birthday

MM

DD

YYYY

Phone

(###)

###

####

Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent or Guardian

If the performer is under 18.

First Name

Last Name

Parent or Guardian Phone

(###)

###

####

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Doctor's Name & Phone #

Medical Insurance Information

Do you have any allergies, food or otherwise?

If none, write "none" or "n/a"

Do you currently suffer from any illness or injury?

If none, write "none" or "n/a"

Do you currently take any medications?

If none, write "none" or "n/a"

Is there any other medical information we should know?

If none, write "none" or "n/a"