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Emergency Contact Form

MEMBER DETAILS:

YOUR EMERGENCY CONTACT DETAILS:

MEDICAL INFORMATION

Do you have any medical insurance

I, the undersigned, being the member or parent/legal guardian of the member, hereby authorize any necessary medical treatment.

I/We authorize the administration of any medications prescribed by a doctor in attendance of this member while under the supervision of Legacy Production Co. while at rehearsal and on any approved trips

I/We guarantee payment of any charges incurred during medical treatment.

I/We hereby certify that the above information in current and correct.

If Member is under 18, Please have parent/Legal Guardian

Which group are you with?

Thanks for submitting!
We’ll contact this person only in case of emergency.

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