Emergency Contact Form

Legal First Name:

Legal Last Name:

Date of Birth:

Email address

If the situation permits, who do you prefer we contact first in the event of an emergency?

Emergency Services (911) Emergency Contact Person (listed below)

EMERGENCY CONTACT Person:

Emergency Contact Primary number:

Emergency Contact Alternate number:

What information are we premitted to share with this contact (check all that apply):

Nature of injury/illness Whether or not emergency personal are being/have been contacted My current location (or changes thereto) Anything asked regarding the emergency Other (list below in Special Comments section)

Are there any "Special Comments" regarding information provided to emergency contact?

Primary Care Physician information:

Insurance information:

Do you have any MEDICAL ALLERGIES?

If YES, please explain:

Do you have any FOOD ALLERGIES?

If YES, please explain:

Do you have any NON-FOOD ALLERGIES?

If YES, please explain:

Is the any "Additional Information" you want to provide?

Emergency Contact Form

Box Office - OnlIne

Ticketing Information

A Public Fit Theatre Company

Join Our Mailing List