Emergency Contact Information "*" indicates required fields Talent InformationName* First Middle Last Birthdate* Month Day Year PhoneEmail Home Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have allergies?* Yes No Do you experience seizures?* Yes No Allergies*Please list one allergy per field and click the + for additional fields. Add RemoveIn case of allergic reaction, what should be done?*Please describe the onset sign of seizure*In case of seizure, what should be done?*Are there any tasks you won't be able to do because of a medical condition?*Please list any medications you take that we must be aware of.*Please list one medication per field and click the + for additional fields. Add RemoveIs there any additional information our staff must know to ensure your safety?*Emergency ContactEmergency Contact Name* First Last Emergency Contact Phone*Emergency Contact Secondary Phone*Emergency Contact Email* Relationship* Parent Sibling Friend Other If Other, please specify relationship:* Doctor Name* Doctor Phone Number*Hospital Affiliation* Medical Insurance Carrier*