Health Form — High Point Community Theatre

Emergency Contact & Medical Form

Name

First Name

Last Name

Emergency Contact Name & Relation

Emergency Contact Phone

(###)

###

####

Food Allergies

Dietary Restrictions

Other Allergies

Ongoing Medical Conditions

How can we help you if the above situation(s) becomes a problem?

Medications you take & other information that the Stage Management Team should know about

All information will be kept strictly confidential and is needed to ensure prompt and proper treatment in cases of emergency.