Nova Woodbury - Emergency Contact / Health Form

1
Name
First Name
Last Name
2
Cell Phone
3
Email
example@example.com
4
Date of birth
Date
Month
Day
Year
5
Name
First Name
Last Name
6
Relationship
7
Primary Phone
Please enter a valid phone number.
8
Alternate Phone
Please enter a valid phone number.
9
Name
First Name
Last Name
10
Relationship
11
Primary Phone
Please enter a valid phone number.
12
Alternate Phone
Please enter a valid phone number.
13
CONDITIONS/ALLERGIES/ISSUES:Please list any medical issues you may have; i.e. asthma, allergies, seizures…
14
Plan of action if a medical issue arises:Please list any medications, epi pens or protocols that can be used during an event.
15
The information requested on this form is confidential and for emergency use only. In the event of an emergency while attending school

the information will be used by Nova Academy of Cosmetology personnel. Please provide accurate, complete and true information.
In case of an emergency, I give permission for my information to be released for emergency purposes. I also agree that any of my
emergency contacts listed on this card may be notified in an emergency, as needed.
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DateCompletion Date
Date
Year
Month
Day
17
Signature
Should be Empty: