2025 Las Vegas - Emergency Contact Form

Emergency Contact Information

Las Vegas Walsworth Workshop (July 29-30, 2025)
This information will be extremely important in the event of an accident or medical
emergency. Please be sure to fill out accurately.
School Name*
Adviser Name*
STUDENT INFORMATION
Student Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Birth Date*

MonthDayYear
Allergies
Medications
Dietary Restrictions/Preferences
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name*

First NameLast Name
Cell Phone Number*
Please enter a valid phone number.
Work Phone Number*
Please enter a valid phone number.
Home/Other Phone Number
Please enter a valid phone number.
Email*
example@example.com
Relationship to student*
INSURANCE INFORMATION
COMPANY*
POLICY NUMBER*
Insurance Card

Upload a photo of your insurance card.
Cancelof
PHOTOGRAPHY RELEASE
By attending this workshop, you are entering an area where photography, audio and video recording may occur.

Your entry and presence on the event premises constitutes your consent to be photographed, filmed, and/or otherwise recorded and to the release, publication, exhibition, or reproduction of any and all recorded media of your appearance, voice, and name for any purpose whatsoever in perpetuity in connection with the workshop organizers, including but not limited to use on websites, in social media, news and advertising.

By entering the event premises, you waive and release any claims you may have related to the use of recorded media of you at the event, including, without limitation, any right to inspect or approve the photo, video or audio recording of you, any claims for invasion of privacy, violation of the right of publicity, defamation, and copyright infringement or for any fees for use of such record media.

You understand that all photography, filming and/or recording will be done in reliance on this consent. If you do not agree to the foregoing, please contact the workshop organizers.
AUTHORIZATION FOR TREATMENT
I hereby give permission to the workshop staff to secure emergency medical and/or surgical treatment for my child while in their care. All expenses of such care will be accepted by the parent(s)/legal guardian, including fees for an ambulance, if deemed necessary by staff. I realize attempts to reach me prior to any decisions will be made unless a life-threatening situation is at hand or circumstances do not allow.
ADDTIONAL INFORMATION
Signature*

Clear
Should be Empty:

Emergency Contact Information

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

INSURANCE INFORMATION

PHOTOGRAPHY RELEASE

AUTHORIZATION FOR TREATMENT