Emergency Medical Form

Date(Required)

Artist Name(Required)

First Last

Preferred Name (if different)

Pronouns

Ex: She/Her, He/Him, They/Them, She/They, Xe/Xem, etc

Honorific

Ex: Ms., Mr., Mx., Ind., Dr., etc

Phone(Required)

Email(Required)

Notification:

First person you wish to have us notify in case of an emergency(Required)

First Last

Relation:(Required)

Phone(Required)

Other ways to contact

Second person you wish to have us notify in case of an emergency (only if the first person is not available)

First Last

Relation:

Phone

Other ways to contact

Allergies and other information you want us to have (medical conditions, medications, etc.)

This information will be kept confidential. It will only be used if needed when determining consumables in a production or in an emergency if you are unable to convey it yourself.