Medical & Emergency Contact Information: Adults – Swamp Donkey Musical Theatre Society

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PARTICIPANT CONTACT INFORMATION:

Participant Name

First

Last

Age

Date of Birth

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

EMERGENCY CONTACT INFORMATION:

Emergency Contact Name

First

Last

Relationship to Participant

Emergency Contact Phone

Emergency Contact Email

MEDICAL HISTORY:

Alberta Health Care Number (optional)

Do you have any medical conditions we should be aware of?

Are you currently taking any medication we should be aware of?

Do you have any allergies?

Family Physician's Name

Family Physician's Phone

I Agree

I confirm the information set out above is accurate to the best of my knowledge, belief, and information.

I understand it is my responsibility to notify the Swamp Donkey Musical Theatre Society of any changes in the above information as soon as possible.

Name

First

Last

Signature

Clear Signature

Date