Emergency Information

 

Cast Members Name______________________________________________________

Parent Name (for CHILD cast members only)    ________________________________

Address________________________________________________________________

City___________________ State__________________Zip_______________________

E-mail address (print CLEARLY)   __________________________________________

Hm phone________________Work___________________Cell___________________

Emergency Contact__________________________ Phone_______________________

If unable to reach Emergency Contact is there anyone else you would like contacted?

______________________________________   Phone__________________________

Physician to be called in emergency_________________________________________

Physician’s phone number_________________________________________________

Allergies to medication____________________________________________________

Hospital Preference_______________________________________________________

Name of Insurance carrier_________________________________________________

In the event of accident or emergency I authorize the directors, Randall Hickman, Douglas Davis,

Jacob Silva, Katie Gonzales, or current PREMIERE show Director to call 911 or take me to

the above named physician or the nearest emergency hospital for such emergency treatment.

__________________________________________            ____________________

Name (parent signature)                                                                           Date