2019 Personal Information Form

Welcome to the 2019 Apprentice Program! This form is to help us gather some important information about you before the summer begins. Information on this form will be shared with the following people as necessary: Academy Director, Academy Coordinator and Academy Administrator, Voice Teacher, Showcase Director, Stage Manager and CSC senior staff (only as needed). Email and phone will be shared on our general company contact sheet. If there is anything that you'd like to share more confidentially, feel free to reach out to Victoria at vtownsend@commshakes.org or 781-710-4766. *

Check to acknowledge

Personal Information

Full name exactly as you would like it to appear on printed materials *

(Ex: program, website, contact sheet)

Affiliation to be listed in the program *

This should either be your school and grad year (for example: Bridgewater State '18) or if not applicable your town of residence/origin (for example: Brooklyn, NY)

Email *

This email will be the primary form of communication during the summer. It is very important it is one that you can check every day.

Cell Phone Number *

Date of Birth *

Age on program's first day (6/9/19) *

Name you prefer to be called *

What pronouns would you like us to use for you during the summer?

For example: She/her/hers; They/Them/Theirs; He/Him/His

Occasionally, CSC may provide meals and/or snacks to Apprentices. Please tell us of any dietary restrictions. *

Please upload a JPEG of the headshot you would like us to use for you this summer *

Please include a short actor bio that you'd like us to use below (max 50 words) *

Medical Information

In the event of a medical emergency please notify: *

First

Last

Emergency Contact 1

Phone *

Emergency Contact 1

Relationship *

Emergency Contact 1

Second Emergency Contact, if applicable

First

Last

Emergency Contact 2

Phone

Emergency Contact 2

Relationship

Emergency Contact 2

Known Allergies

Medicines Taken

Insurance Carrier and Number

Physician's Name and Phone

Any ongoing treatments or conditions you wish to disclose at this time?

Please include any other information you would want known in a medical emergency

Is there anything else you would like us to know?

Message

What are you looking for?

Personal Information

Medical Information