Arc Stages Medical Form
Medical and Release Form
Actor's First Name *
Your answer
Actor's Last Name *
Your answer
Parent/Guardian Names *
Your answer
Home Phone #
Your answer
Parent Cell Phone # *
Your answer
Parent Work #
Your answer
Cell/Alternate #
Your answer
IN CASE OF EMERGENCY, IF PARENT CANNOT BE REACHED, CONTACT:
Emergency Contact Name 1 *
Your answer
Cell Phone # *
Your answer
Emergency Contact Name 2
Your answer
Cell Phone #
Your answer
Health History
The following information will be released to the Teaching and Production Staff of Arc Stages, as well as any emergency medical personnel, so that any necessary and/or appropriate accommodations can be made to ensure the safety of your child and to enable your child to successfully participate in the Theatre's programs. Please indicate health problems or disabilities that may require any accommodations:
Please explain in detail any of the above health issues:
Your answer
Does your child have asthma?
If yes, does your child have an inhaler or other medication that should be administered?
If medication is to be administered while at Arc, please indicate the name of the medication and the dosage, as well as conditions under which it should be administered.
Your answer
Is your child allergic to any of the following? (check all that apply)
Please explain in detail any of the above allergies:
Your answer
Is your child currently taking any medication?
If yes, please describe condition and medication:
Your answer
If your child will be taking medication while at the theatre, please include the name and dosage, as well as conditions under which it should be administered, or times at which it should be administered.
Your answer
Does your child have any chronic or recurring illness? (Please describe)
Your answer
Any specific activities to be limited or encouraged by physician's advice?
Your answer
Any dietary restrictions? (please describe)
Your answer
Medical Release
Insurance Company & Number (optional)
Your answer
Name of Child's Doctor
Your answer
Doctor's Phone#
Your answer
Doctor's Address
Your answer
In case of an emergency, you hereby give permission to the staff and volunteers of Arc Stages to contact and/or provide emergency medical assistance. Arc Stages is not responsible for the quality of any medical treatment administered to your child by any emergency medical personnel.
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