Company Member Emergency Information

Your Information

Your Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Cell Phone*

Date of Birth*

Email*

Enter Email Confirm Email

(Please enter your email in each box above so we make sure there are no typos.)

Are you currently 18 or older?*

Yes, I am currently 18 or older.

No, I am currently 17 or younger.

Gender*

Male

Female

Your Primary Care Doctor's Name and Phone Number:*

Person to contact in case of an emergency, their phone number, and relationship to you:*

Do you have any allergies including medicinal, food, fabric, detergent, aerosol spray, etc. that you would like to share with our management?*

Do you wear contact lenses?*

Yes

Is there any other medical information that you would like to share with our management? (Medical conditions, medications you are taking, etc. that we should be aware of in case of an emergency.)*

Parent/Guardian Information

Parent/Guardian Name*

First Last

Parent/Guardian Email Address*

Enter Email Confirm Email

(Please enter your email in each box above so we make sure there are no typos.)

Parent/Guardian Work Phone

Parent/Guardian Cell Phone*

Relationship to teen?*

Mother

Father

Other

Additional parent/guardian?*

Yes

Additional Parent/Guardian Name

First Last

Additional Parent/Guardian Email Address

Enter Email Confirm Email

(Please enter your email in each box above so we make sure there are no typos.)

Additional Parent/Guardian Work Phone

Additional Parent/Guardian Cell Phone

Relationship to teen?

Mother

Father

Other

Medical Release

I agree to indemnify the All Saints Parish, Youth Ministers, Volunteers, Upper Room Theatre Ministry, and the Diocese of Arlington for any costs or expenses arising out of my child’s participation in the activities including the cost of any medical care given my child or any expenses or fees incurred in any lawsuit arising as a result of any damage or injuries caused by my child in the course of his or her participation in the activity. I further give my consent to that in my absence the previously-named minor be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the previously-named minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor.

Medical Release Signature (MUST BE SIGNED BY PARENT IF YOU ARE 17 OR YOUNGER):*

Please sign in the box above using your mouse (or your finger if you’re on a tablet). ***This must be signed by a parent if you are 17 or younger.**

Print Your Name for Medical Release*

***This must be completed by a parent if you are 17 or younger.**

In case of an emergency and if treatment is needed:*

You may treat my child immediately without contacting me first.

If possible, please attempt to contact me first before treatment.

Do we have permission to provide over-the-counter medications to your child? If so, which ones? (Examples: Tylenol, Advil, throat lozenges, etc.)*

Your Information

Parent/Guardian Information

Medical Release

Our Performance Location

Contact Us

Plan Your Visit

Support Upper Room

About Us

Our Shows