Emergency Contact Form

MEMBER DETAILS:

First name

Last name

Phone

Address

YOUR EMERGENCY CONTACT DETAILS:

Contact First Name

Contact Last Name

Contact Phone Number

Contact Email

MEDICAL INFORMATION

Do you have any medical insurance

Yes

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.

Member Signature

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

Your Signature

Which group are you with?

Legacy

Miami Lakes Percussion

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