Studio East Adult Emergency Form

Studio East must have an emergency form on file for you any time you teach or participate in classes, camps, workshops, and productions.
We collect the information using this electronic emergency form which we will keep it on file for you from September through June.  Those working or participating in our Summer programs will be asked to fill out a new form.
When you have any changes to your emergency form information, please submit a new form or contact the office and we will send you the link to this form again.

Step 1: Your Identifying Information

Primary phone is: *
Secondary phone is: *

Step 2: Publicity Permission

Step 3: Emergency Contacts Information

Please give us contact information for two people whom we can contact should that be necessary.
Emergency Contact #1
Emergency Contact #2

Step 3: Emergency Medical Information

Is there any information that Emergency Medical Personnel would need to know?
Medical Condition? *
Medication *
Allergies *

Medical Personnel would need the following information:

Complete this section if you answered YES to any of the Medical Questions above.

Medication Information

Please enter any medications we should be aware of:

Allergy Information

 
Please enter any severe allergies we should be aware of:

Authorization

I, the undersigned, acknowledge the possibility that participation in Studio East activities could result in physical injury.  I hereby release, discharge, and agree to hold harmless Studio East, its officers, directors, employees, agents and affiliates from any and all claims arising from or related to participation in Studio East activities.  I further authorize Studio East staff to obtain medical care for me in case of an emergency.  
 
I certify that I have read, understood, and agree to the above conditions, and that the information provided on this entire form is complete and accurate to the best of my knowledge.