Student's Name *
Student's Name
Date of Birth
Date of Birth
Contact Mailing Address
Contact Mailing Address
Contact Name 1
Contact Name 1
Contact Phone 1
Contact Phone 1
Contact Name 2
Contact Name 2
Contact Phone 2
Contact Phone 2
Doctor's Name
Doctor's Name
Doctor's Phone
Doctor's Phone
Please include physical, social, psychological if relevant, i.e. allergies, asthma, etc.
Emergency Contact 1
Emergency Contact 1
In the event of an emergency, please list in order of preference the people to be contacted.
Emergency Contact 1: Phone
Emergency Contact 1: Phone
Emergency Contact 2
Emergency Contact 2
Emergency Contact 2: Phone
Emergency Contact 2: Phone
Emergency Contact 3
Emergency Contact 3
Emergency Contact 3: Phone
Emergency Contact 3: Phone
In the event of a medical emergency your child will be taken to Northern Dutchess Hospital in Rhinebeck and this form will be given to the doctor on call. List below any and all information you feel important for the staff or doctor to know.
Checkbox
I authorize the Cocoon Theatre staff to follow emergency medical procedures as they feel necessary. I have read the Welcome Letter and I agree to the workshop requirements. I have made any special preferences and indications known.