Medical and Emergency

MEDICAL AND EMERGENCY INFORMATION

* Indicates required field

Member Name *

First

Last

Emergency Name (Primary) *

First

Last

Relation (P) *

Phone Number (P) *

Emergency Name (Secondary) *

First

Last

Relation (S) *

Phone Number (S) *

Physician *

Physician’s Phone *

Medical/Hospital Insurance Company *

Policy Holder’s Name *

Policy Number *

Allergies *

Medical Conditions *

Drug Allergies *

Medications *

Food Allergies *

As an organization, we have made the decision that all staff, performers (12 and older), and volunteers to be vaccinated. There are certain case by case situations, listed below, that are taken in consideration.

Vaccine against COVID-19 is readily available at multiple pharmacies. To find a COVID-19 vaccination clinic near you: Visit the NJ COVID-19 Vaccine Appointment Finder: https://covid19.nj.gov/pages/finder or call NJ Vaccine Call Center at 855-568-0545.

Acceptable proof of vaccination includes:

The CDC COVID-19 Vaccination Card issued to the vaccine recipient by the vaccination site, or an electronic or physical copy of the same;
Official record from the New Jersey Immunization Information System (NJIIS) or other State immunization registry;
A record from a health care provider’s portal/medical record system on official letterhead signed by a licensed physician, nurse practitioner, physician’s assistant, registered nurse or pharmacist;
A military immunization or health record from the United States Armed Forces; or
Docket mobile phone application record or any state specific application that produces a digital health record.

Have you received the COVID vaccination? *

Yes No

Upload Proof Of Vaccination Card *

Max file size: 20MB

If no, please select reason why: *

Medical Exemption Religious / Strongly Held Personal Reason

EXCEPTIONS:
If requesting a medical exception from COVID-19 vaccination due to one of the following contradictions below:

Allergy to the vaccine or components as defined by the most current recommendations of the CDC: Refer to CDC website.

If requesting a religious / personal exception due to reason below:

Because the requested vaccination conflicts with my sincere held religious and/or strongly held beliefs and practices.

Is there any other explanation for which you would like to comment? *

*If you are not vaccinated, I understand and agree that I will follow CDC recommendations for non-vaccinated individuals, including but not limited to, wearing a mask, social distancing, and frequent hand washing. For more information, please visit the CDC website: www.cdc.gov.

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