Peacock Players Medical Information Sheet

Show: ________________________

CONFIDENTIAL

Date of Original File:_____/_____/_____ Updated_____/_____/_____

This form requests basic emergency and insurance information. The theatre must have it on file to assure safe participation in classes, camps, and productions. This information will only be used in the event of an emergency.

PLEASE FILL OUT THIS FORM ASAP, AND RETURN IT TO THE THEATRE.

Name of Child: ___________________________________________________________________

Date of Birth:_____/_____/_____

Insurance Co.: ____________________________________________________________________

Policy #: _______________________________________

Policyholders Name: _______________________________________________________________

Please list two people we should contact in case of emergency.

Name: _______________________________ Name: ________________________________

Address: ________________________________ Address: __________________________________

________________________________________ _________________________________________

Home Phone: ____________________________ Home Phone: ______________________________

Work Phone: _________________________ Work Phone: ______________________________

Please list and give details regarding any allergies, chronic conditions, or medications that should be made known to a doctor in case of emergency.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

If you have specific instructions regarding your medical care (i.e. particular hospital or practitioner, health plan authorization, etc.) please describe.

_____________________________________________________________________________________________

_____________________________________________________________________________________________