Emergency Information Form Name: Date of Birth: Home Phone #: Cell Phone #: Address: Email: Health Insurance Provider: Policy #:

Emergency Contact Information Please provide contact information for two people to notify in case of an emergency.

Name: Name: Phone #: Phone #: Relationship: Relationship:

Please inform your emergency contact that you have listed them here so that they are better informed to make decisions.

Medical Info Please list any allergies, medications, physical impairments or medical conditions that may affect

you during the run of the show.

In case of emergency, I give my permission to be treated by emergency personnel/clinic/hospital.

Name (print): Date: Signature: **Please complete and return to a member of the stage management team before you leave rehearsal today.**