arts2work emergency Contact Form

This information will be extremely important in the event of an accident or medical emergency.

Name

First Name

Last Name

Phone

(###)

###

####

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Emergency Contact

First Name

Last Name

Relationship

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Secondary Emergency Contact

First Name

Last Name

Relationship

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Preferred Hospital

In case of an emergency, what hospital would you like to be transported to?

Insurance Information

Company

Policy #

Additional Health Information

Accessibility Needs

Please outline any accessibility needs you may have and what you think we can do to support them.

Allergies

Please list all food/medical allergies.

Medications

Please list any medications that you are currently taking that we need to be aware. *This is so in the event of a medical emergency we are fully informed.

Existing Medical Conditions

Please share any existing medical conditions or chronic illnesses you would like our staff to know about.

Dietary Restrictions

Please share any dietary restrictions or preferences

Comments

Please include any special medical or personal information you would want an emergency care provider to know.

I have voluntarily provided the above contact information and authorize Youth FX administrative staff to contact any of the above on my behalf in the event of an emergency.

Youth FX Inc. is 501c3 non-profit organization supported by our community and the following partners:

Arts2Work Emergency Contact Sheet

arts2work emergency Contact Form

Youth FX