Mary Poppins JR. EMERGENCY Form
Please have this form filled out on or before TUESDAY 8/21

THIS IS NOT A REGISTRATION FORM

Youth Performer's Information
Please fill this form our in it's entirety. This information is crucial for production staff to have on hand in the event of an unlikely emergency.
Performer's Name *
Last, First
Your answer
Performer's Email *
Only with parent's consent
Your answer
Performer's Cell *
000-000-0000
Your answer
Age *
Your answer
Grade *
Your answer
School & City *
School (in Fall) / City of School
Your answer
Date of Birth *
mm/dd/yyyy
Your answer
Please list any known allergies here. *
Your answer
Healthcare Provider / Medical Number *
Your answer
Wonderland CAST is your child in?
Parent Information
Please note that those indicated as parents 1 & 2 below will be acknowledged for authorized pick-up.
Valid ID may be required for pick-up
Parent 1 Name *
Your answer
Parent 1 Cell Phone *
Your answer
Parent 1 Home Phone *
Your answer
Parent 1 Work Phone *
000-000-0000 (ext)
Your answer
Parent 1 email *
Your answer
Parent 2 Name
Your answer
Parent 2 Cell Phone
Your answer
Parent 2 Home Phone
Your answer
Parent 2 Work Phone *
000-000-0000 (ext)
Your answer
Parent 2 email
Your answer
Authorized Pick-Up
Please list additional adults authorized to pick your child up from rehearsals or shows. Valid ID may be required for pick-up
Your answer
Emergency Contacts
Those listed below are responsible adults in addition to Parents 1 & 2.
Contact 1 Name
First Name Last Name
Your answer
Contact 1 Cell Phone
000-000-0000
Your answer
Contact 1 Home Phone
000-000-0000
Your answer
Contact 2 Name
First Name Last Name
Your answer
Contact 2 Cell Phone
000-000-0000
Your answer
Contact 2 Home Phone
000-000-0000
Your answer
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