Medical and Emergency Contact Information: Minors

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PARTICIPANT CONTACT INFORMATION:

Participant Name
Address

PARENT/GUARDIAN CONTACT INFORMATION:

PARENT/GUARDIAN #1:

Parent/Guardian 1 Name
Parent/Guardian 1 Address

PARENT/GUARDIAN #2:

Parent/Guardian 2 Name
Parent/Guardian 2 Address

EMERGENCY CONTACT INFORMATION:

Emergency Contact Name (Individual Other than Parents/Guardians)

MEDICAL HISTORY:

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.
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