Emergency Action Form
The original of this form will be kept securely at Stage Door, and will be accessed by designated staff in an emergency only.
Name
*
First Name
Last Name
Position/Show
*
London Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
phone number
*
Home Address (if different to above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If you failed to appear at work, who would we contact who has access to your house?
*
Contact's phone number
*
Relation
*
If you were taken ill or had a serious accident, who should we contact in the first instance?
*
Contact 1
Contact one's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
contact one's phone number
*
Notes:
contact Two's NAME
*
contact two's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CONTACT TWO'S PHONE NUMBER
*
Notes:
Is there any other action you would like us to take (eg childcare arrangements)?
Do you have any pre-existing medical conditions/injuries that we should be aware of?
*
This information may speed up treatment in the event of an emergency, and will help us to make reasonable adjustments during your time with us
Do you have anY allergies?
*
Yes
No
If you've answered yes, please give details including if you carry any medication with you?
The following questions relate to Covid-19, and will help us create accurate Risk Assessments for the project(s) you are involved with at the Unicorn. Have you had three doses of the Covid-19 vaccine?
*
Yes
No
Prefer not to say
Have you been invited to have a seasonal booster (a 4th or 5th dose) of the vaccine for Winter 2022?
*
Yes, I have had this booster (please give date below)
Yes, I plan to have this booster (please give date below)
Yes, but I do not plan to have it
No
Prefer Not to Say
Other
If you answered 'yes I have / plan to have this booster' please give us the date if you have it:
-
Month
-
Day
Year
Date
Please give us the date of your most recent positive test for Covid (LFT or PCR):
-
Month
-
Day
Year
Date
Are you exempt from wearing a face covering?
*
Yes
No
Is there anything else involving your health and Covid-19 that we should be aware of?
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: