Health declaration and show consent

Please fill out the following form.

It is important that this information is completed carefully and honestly to ensure the full safety of cast members.

The information is confidential and will be treated as such; it will be kept securely and only shared with members of Congress Players Committee where absolutely necessary, and / or healthcare providers if required.

When it is necessary to destroy the information it will be done so securely.

If cast member is under 18, this form must be filled by Parent or Legal Guardian.

Cast Member's First name

Last name

Pronoun(s) if desired.

Date of birth

Day

Month

Year

Home address

Country/Region

Address

City

Zip / Postal code

Emergency Contact information 1. Name, relationship and phone numbers(s)

Emergency Contact information 2. Name, relationship and phone numbers(s). If Under 18, this is mandatory.

Email

Phone number of cast member

If in education, name of school / college

If under 16, who has legal guardianship?

Consent

I confirm that the above named is fit to perform in the production of "Everybody Is Talking About Jamie" July 2025, and if this status changes at any time I shall inform a member of Oldham Congress Players committee

Signature. (Parent / Guardian if under 18)

Signature field is empty.

Date

Day

Month

Year

I consent to allow the application of stage makeup to the above named.

Signature. (Parent / Guardian if under 18)

Signature field is empty.

Date

Day

Month

Year

I consent to allow filming, photographs, and audio recording of the above named during the rehearsal process and production

Signature. (Parent / Guardian if under 18)

Signature field is empty.

Date

Day

Month

Year

I consent to allow approved film, photographs and audio footage taken during rehersal and production process of the above, to be used for the promotion of the production and organisation, and acknolwdge that Congress Players hold no control over the onwards sharing of this material by others

Signature. (Parent / Guardian if under 18)

Signature field is empty.

Date

Day

Month

Year

Medical Information

Does the cast member have any of the below:

History of Heart Problems

No

Yes

History of Diabetes

No

Yes

Asthma / Breathing Problems

No

Yes

Epilepsy / Seizures / Blackouts

No

Yes

Bleeding Disorders

No

Yes

Allergies to anything (medicines, food, substances)

No

Yes

Carry a warning card or SOS carrier

No

Yes

Taking any medications, tablets, drugs, creams / ointments

No

Yes

If you answered yes to any of the questions above, please supply additional information, including list of allergies and medications taken.

Does the person have a disability

No

Yes

If yes, please give details

Does the person wear glasses / contact lenses

No

Yes

Anything else you consider important relating to health or ability

Name and address of Doctor

Information provided by (Parent / Guardian if child)

Signature

Signature field is empty.

Date Completed

Day

Month

Year

I declare that the info I’ve provided is accurate and complete.

Health declaration and show consent

Consent

Medical Information

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