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:

By submitting this 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 and bring it to the next dance to be put in our files.