Medical Release *OPTIONAL* Medical information requested in this form is not required for participation with Primary Players. We DO need this form signed by a parent, however. If you decide not to share this medical information, please sign a blank Medical Release form at rehearsal. Student Name* First Middle Last Emergency Contact:*RelationshipPhoneAllergiesCurrent MedicationsPrevious SurgeriesInsurance Carrier*Family Doctor*EmployerEmployer's Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I hereby authorize Primary Players Children's Theatre Group to call 9-1-1 or to arrange for transportation to the nearest hospital in the event of a major injury.* I Agree NameThis field is for validation purposes and should be left unchanged.
