Contact Information
The following section will be kept confidential and will only be used in the case of an emergency.
Last Name

First Name

Local Address
Your Position with PCPA:
Acting Intern
Tech Intern
Guest Director/Designer
Guest AEA Actor
2-year Tech Student
2-year Acting Student
Staff or Faculty
Email
  Cell Phone
In Case of Emergency Information

The following section is optional and will only be used in case of emergency.
All information will be kept confidential on a private drive and it will be destroyed once you are no longer with PCPA.

Date of Birth (mm-dd-yy)
In Case of Emergency Notify:
Local Contact: Name
Relationship
Phone
Alternate Phone
Address
City
State
Zip Code

Other Contact: Name
Relationship
Phone
Alternate Phone
Address
City
State
Zip Code

Are there any medical conditions or allergies that you think we should know about?
If so, please enter them in the fields below.
Medical Allergies (include foods/beverages/chemicals, detergents, etc.)
Current Medications
Medical Conditions
Phobias
Dietary Restrictions (gluten free/vegan, etc.)
Recent injuries/surgeries
Check if you wear contacts?
Yes
Check if you wear glasses?
Yes
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