Boots 'n' Buckles Dance Club

ICE (In Case of Emergency)

Contact Form





* required field

* First name:        * Last name:

      
* Home Phone:                    Cell Phone:


* Emergency Contact #1:

Home Phone:   * Cell Phone:


   Emergency Contact #2:

   Home Phone:       Cell Phone:



* Physician Name:

* Medical Facility:              * Phone:


Signature:                                                                              Date:                           

By submitting this signed form, the dancer voluntarily releases the above information to the
Boots 'n' Buckles Dance Club board members to be used in the event of an emergency.

Click on the 'PRINT' button below to print out your filled-in ICE form, sign on the signature
line, and bring the completed form to the next dance to be put in our files.
By clicking PRINT a new tab may appear.  Close the new tab and you will see the print box.