Medical Information
The following information will be used only by medical personnel in case of a medical emergency (please give all information correctly - if none, please write "none"):
* Required
Name
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Your answer
Mailing Address
*
Your answer
Emergency Contact (Name)
*
Your answer
Relationship to Emergency Contact
*
Your answer
Best Phone Number for Emergency Contact
*
Your answer
Allergies (include any medication/foods you are allergic to):
*
Your answer
Medical Conditions or Diagnoses:
*
Your answer
Name and Dosages of Medication:
*
Your answer
Please list any other pertinent information that an EMT might need to assess your case:
*
Your answer
PLEASE READ CAREFULLY
I RECOGNIZE THAT BEING A MEMBER OF THE CAST AND/OR PRODUCTION CREW OF THIS STERLING PLAYMAKERS SHOW INVOLVES SOME RISK AND BY AGREEING TO BE IN THE CAST AND/OR ONT HE PRODUCTION CREW, I UNDERSTAND THAT RISKS INVOLVED WITH THIS TYPE OF ACTIVITY. I UNDERSTAND THAT NEITHER THE STERLING PLAYMAKERS NOR LOUDOUN COUNTY PUBLIC SCHOOLS OR OTHER FACILITIES ASSUME ANY RESPONSIBILITY FOR ANY ACCIDENTS AND/OR MEDICAL TREATMENT IF NECESSARY.
By completing and submitting this form you agree to the terms and conditions of this Medical Information form
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Full Name of Volunteer or Parent on Behalf of Volunteer
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Your answer
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