Lincoln Trojan Band Medical Information Form
Student Information
Student Name
*
First Name
Last Name
Student Date of Birth
-
Month
-
Day
Year
Date
Student Grade
Emergency Contact
Emergency Contact #1 - Name
*
First Name
Last Name
Emergency Contact #1 - Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #1 - Email
example@example.com
Emergency Contact #1 - Relationship to Student
*
Emergency Contact #2 - Name
First Name
Last Name
Emergency Contact #2 - Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2 - Email
example@example.com
Emergency Contact #2 - Relationship to Student
Do you want to add an additional contact?
Yes
No
Additional Emergency Contact
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Relationship to Student
Medical Information
Check all that apply to the student.
*
Allergy (describe below)
ADD/ADHD
Asthma
Anxiety
Convulsions/Siezures
Diabetes
Epilepsy
Hearing Difficulties
Heart Trouble
Hemophilia
High Blood Pressure
Hyperventilation
Knee/Back Injuries
Migraines
Other (describe below)
None
Please describe any additional medical information (e.g., allergies)
Medications student is taking or might have to take while participating in a band activity.
Submit
Should be Empty: