Emergency Medical Form printable pdf download

Emergency Medical Form

PART 1: Authorization to Seek Medical Treatment

I, the undersigned, do hereby authorize representatives of StarStruck Theatre to

serve as agents for the undersigned to consent to any necessary medical treatment.

In the event your child is injured or an emergency occurs, SS will make every effort

to reach you. If you cannot be reached, SS will try to reach your emergency contact.

If possible, SS will call your designated doctor or dentist. However, if deemed

necessary because of the nature of the injury or emergency, SS will obtain treatment

from the nearest hospital.

Actor Name (print):_______________________________Date: _______________

Actor Signature: (if over 18)

_____________________________________________________

Parent's Signature:

___________________________________________________________

PART TWO: Emergency Contacts (list parents/guardians first)

Name

Day Phone

Evening Phone

Relationship

Parent/guardian 1

Parent/guardian 2

Primary Care Physician:____________________________________

Phone #: ____________________

Insurance Company:_______________________________________

Policy #: ____________________

Policy holder name and phone:

__________________________________________________________

Drug

allergies:___________________________________________________________

Emergency Medical Form