EMERGENCY MEDICAL INFORMATION & RELEASE OF LIABILITY

Pageant Weekend Emergency Contact - Name*

(Other than your own)

Pageant Weekend Emergency Contact - Phone Number*

(Other than your own)

Relationship to Contestant*

Allergies (Any Medications or Foods)*

Current Medications (Prescription or Non-Prescription)*

Medical Conditions*

List any RECENT illness, injury, or surgery*

List any medical or physical conditions that might limit your ability to participate in this pageant

Name of medical insurance carrier*

Policy and Group Number*

Insurance Company Phone*

Mother's Name*

Please list your mother's first and last name. Should you choose not to list anyone, please enter "None" in the field above.

Mom's Cell Phone*

If you did not enter your mother's name in that field, please enter "000-000-0000" in this field.

Father's Name*

Please list your father's first and last name. Should you choose not to list anyone, please enter "None" in the field above.

Father's Cell Phone*

If you did not enter your father's name in that field, please enter "000-000-0000" in this field.

In consideration of participating in the Houston USA pageant and its related events and activities, I agree that:

There are inherent risks of injury.
I knowingly assume those risks and agree to indemnify and hold harmless, the pageant director, Ché White, and Divine Dreams, LLC. for all injuries sustained, except those caused by the sponsoring director’s sole negligence.

Contestant - Date Signed*

Parent/Guardian - Date Signed

Emergency/Medical Information and Release of Liability