Medical Information

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Medical Information

The following information will be used only by medical personnel in case of a medical emergency (please give all information correctly - if none, please write "none"):

Name *

Mailing Address *

Emergency Contact (Name) *

Relationship to Emergency Contact *

Best Phone Number for Emergency Contact *

Allergies (include any medication/foods you are allergic to): *

Medical Conditions or Diagnoses: *

Name and Dosages of Medication: *

Please list any other pertinent information that an EMT might need to assess your case: *

PLEASE READ CAREFULLY

I RECOGNIZE THAT BEING A MEMBER OF THE CAST AND/OR PRODUCTION CREW OF THIS STERLING PLAYMAKERS SHOW INVOLVES SOME RISK AND BY AGREEING TO BE IN THE CAST AND/OR ONT HE PRODUCTION CREW, I UNDERSTAND THAT RISKS INVOLVED WITH THIS TYPE OF ACTIVITY. I UNDERSTAND THAT NEITHER THE STERLING PLAYMAKERS NOR LOUDOUN COUNTY PUBLIC SCHOOLS OR OTHER FACILITIES ASSUME ANY RESPONSIBILITY FOR ANY ACCIDENTS AND/OR MEDICAL TREATMENT IF NECESSARY.

By completing and submitting this form you agree to the terms and conditions of this Medical Information form *

Agree

Disagree

Required

Full Name of Volunteer or Parent on Behalf of Volunteer *

YYYY

Time

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