Randazzo Dance Company Emergency Contact Form 2017
Dancer's Name
Your answer
Birth Date
MM
/
DD
/
YYYY
Dancer's Home Address
Your answer
Parent/Guardian Name
Your answer
Parent/Guardian Cell Phone
Your answer
Parent/Guardian Home Phone (if applicable)
Your answer
Parent/Guardian Work Phone (if applicable)
Your answer
Please list the name, relationship, and phone number of people you would like notified in case of an emergency
Your answer
Any Known Allergies or Medical Conditions? (if yes, please explain)
Your answer
Any Medications that we need to be aware of? (if yes, please explain)
Your answer
In the case of an emergency, I give permission for my information to be released to emergency personnel. I also agree that any of the contacts listed may be notified in an emergency, as needed.
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