Emergency Contact Information form
University of Kentucky  Summer Dance Intensive -  2022
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Participant's Name *
DOB/ Age *
Participant's cell phone number *
participant's address *
Participant's email address *
Parent/Guardian (#1)  name
Parent/Guardian (#1)  phone number
Parent/Guardian (#1)  address if different from participant
Parent/Guardian (#1)  email address
Parent/Guardian (#1) Employer and Employer contact information
Parent/Guardian (#1) permission to pickup
Parent/Guardian (#2)  name
Parent/Guardian (#2) phone number
Parent/Guardian (#2)  address if different from participant
Parent/Guardian (#2)  email address
Parent/Guardian (#2) Employer and Employer contact Information
Parent/Guardian (#2) permission to pick up
In case of emergency, accident, or serious illness, I request the University of Kentucky, Department of Theatre and Dance or Holmes Hall to contact me. If  the University of Kentucky, Department of Theatre and Dance or Holmes Hall personnel are unable to contact me, I hereby authorize them to call the following people to pick up my child from the Summer Dance intensive or Summer Dance Intensive-sponsored activity. Please list up to TWO individuals.           Individual #1 (first name, last name, phone number and relationship to participant. ) *
Individual #2  (first name, last name, phone number and relationship to participant. ) *
I further understand that the intent of this form is to clearly inform me there are some risks involved in each activity and that by signing below, I am giving my permission for my child to participate in the summer dance intensive. If the participant is 18 or older, by signing below they acknowledge the statement. *
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