2025 Castle Band Medical Form

Castle High School, Newburgh, IN - Warrick County School Corporation
Student Last Name
Student First Name
Graduation Year
Birthdate

MonthDayYear
Date
Student Cell Phone
Student Home Phone
Fall of 2025 Grade (9,10,11,12)
Student Address

Student Address

Street Address Line 2

CityState

Postal / Zip Code
Father/Guardian
Cell Phone
Home Phone
Place of Employment
Mother/Guardian
Cell Phone
Home Phone
Place of Employment
Date of Students Last Tetanus Injection

MonthDayYear
Date
Physicians Name
Phone Number
Insurance Company
Policy Number
List Medications currently taking
List reasons for taking medication
List Allergies
Special Dietary Needs
OTHER CONTACT INFORMATION (if different than above)
Emergency Contact 1
Relationship
Cell Phone
Home Phone
Emergency Contact 2
Relationship
Cell Phone
Home Phone
In case of accident or serious illness, parents/guardians/relatives/friends will be contacted. If they cannot be contacted, and the above named needs emergency medical treatment, consent is hereby given for such emergency treatment as may be considered necessary in the opinion of the attending physician. Authorization is also given for any of the listed medications on this form to be administered, if necessary, to the above named individual.
Digital Signature

Clear
Date

MonthDayYear
Date
Should be Empty: