Health Questionnaire

First Name:*

Last Name:*

Emergency Contact Full Name:*

Emergency Contact Phone Number:*

Relationship To You:*

Do you have a long-term condition or illness that you currently manage?:

If Other, please provide details::

How best can Audley Brass support you, for example if you were taken ill due to your long-term condition or illness at a rehearsal?:

I confirm that I consent for details of my long term condition, illness and subsequent support can be retained by Audley Brass in a secure manner:

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