2026 Castle Band Medical Form

2026 Castle Band Medical Form
Student Name

First NameLast Name
Graduation Year
Fall of 2026 Grade
Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother/Guardian

First NameLast Name
Mother/Guardian Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mother/Guardian Place of Employment
Father/Guardian

First NameLast Name
Father/Guardian Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Father/Guardian Place of Employment

Physician Name

First NameLast Name
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company Name
Policy Number
Student DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Last Tetanus Injection
If none, please enter N/A
List Allergies
If none, please enter N/A
List Special Dietary Needs
List Current Medications
If none, please enter N/A
List Reasons For Taking Medications
If none, please enter N/A

Other Contact Information (if different from above)
Emergency Contact #1

First NameLast Name
Relationship
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2

First NameLast Name
Relationship
Cell Number
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 listedmedications on this form to be administered, if necessary, to the above named individual.
Digital Signature
Should be Empty: