Child Actor Medical Certificate Form
Complete this form to provide the required information for issuing a child actor medical certificate. All details are necessary for the assessment and certification process.
Child’s Identifying Details
Child’s Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Other
Parent/Guardian Contact Information
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Child
*
Mother
Father
Legal Guardian
Other
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Production Details
Production Name
*
Production Contact Person
Production Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Screening
Does the child have any medical limitations that could affect participation in acting activities?
*
No
Yes (please specify below)
If yes, please specify medical limitations
Has the child had any recent illness, injury, or surgery in the past 6 months?
*
No
Yes (please describe below)
If yes, please describe illness, injury, or surgery
Emergency Contact Information
Emergency Contact Name
*
Emergency Contact Relationship to Child
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Authorization
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
Clinician/Certificate Details
Clinician Name
*
Clinician Qualification/Title
*
Date of Examination
*
-
Month
-
Day
Year
Date
Clinician Signature
*
Submit
Submit
Should be Empty: