Emergency Medical Form

Department of Theatre Arts Emergency Medical Information Sheet

This information will be kept confidential, and will only be used in the case of a medical emergency.
Name (First and Last)
Pronouns
Phone
Birthday
Email
example@uwlax.edu
Address
Emergency Contact Information:
Person to notify
Relationship
Phone(s)
Are you currently being treated for any medical condition? If yes, please specify.
Allergies (including foods)
Are you currently taking any prescription or non prescription medications? If yes, please specify.
Have you recently received treatment, had any procedures, or taken any preventive measures for any health-related issues ? If yes, please specify.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: