Emergency Contact And Dcyf Demographic Form printable pdf download

Emergency Contact And Dcyf Demographic Form

MARSH YOUTH THEATER EMERGENCY RECORD

Please print numbers and e-mail clearly and fill out the ENTIRE FORM (3 Pages)

Student's Name________________________________ Date of Birth ___________________

School__________________________________________ Current Grade_____________________

Contact Parent/Guardian's Name__________________________________________________

Home Address ____________________________City, State________ ZIP_____________________

Home Phone _________________WORK/CELL__________________ e-mail ___________________

Other Parent/Guardian's Name ____________________________________________________

Home Address ___________________________City, State_________________ ZIP__________

(if different from above)

Home Phone __________________WORK/CELL__________________ e-mail ______________

Local Physician's Name ________________________Office Phone ______________________

Office Address _____________________________________________________________________

Dentist's Name ______________________________ Telephone___________________________

Health Insurance Company and Number __________________________________________

Does your child take any medication and/or have any allergies?

Is any restriction of physical activity needed?

Is there anything else you would like us to know about your child?

__________________________________________________________________________________

List contacts who will assume temporary care of your child if you cannot be reached:

Name___________________________ Relationship ___________Phone_____________________

Name___________________________ Relationship ___________ Phone_____________________

Family Contact outside of CA ________________________ Phone__________________________

(In case of earthquake, phones will work better by calling out of state)

In case of a major emergency and we could not contact parents or medical help, is there any

medical condition the theater should know about or any medication the theater should have on

hand? ___________________________________________________________________________

PLEASE TURN FORM OVER AND CONTINUE>>>>

Emergency Contact And Dcyf Demographic Form