KACHEA Co-Op Health Form 2022-2023

Student's name

M F

Age

DOB

Grade

Address

Street Address Line 2

City State

Zip

Father

Phone contact preference

Home Cell

Home phone

Cell phone

Mother

Phone contact preference

Home Cell

Home phone

Please enter a valid phone number.

Cell phone

Emergency Information: In an emergency when parents cannot be reached, please contact:

Name

Phone contact preference

Home Cell

Home phone

Cell phone

Please enter a valid phone number.

Medical Information

If there are any known allergies, you must fill out the additional Allergies Form with the details. If there are no known allergies, you do not need to complete the additional form.

Does the student have any known allergies?

No If yes, please list below and complete the additional allergies form

Allergies

Other medical conditions

Regular medicine

Student's physician

Physician's office phone

PARENT’S MEDICAL RELEASE AUTHORIZATION

My child is physically, mentally and emotionally capable of participating in a cooperative school with other students. I understand that during any of the classes there may be games that require physical exertion. While injury is unlikely, I understand that the possibility exists.

I give my consent to have a doctor of medicine provide my child with medical assistance and/or treatment if necessary and agree to be financially responsible for the reasonable cost of such assistance and/or treatment. I understand that treatment would be administered if, in the opinion of medical personnel, it is immediately necessary and I cannot be reached in reasonable time to give consent.

WAIVER OF LIABILITY
I understand that by placing my child in the Co-Op program, I waive and release any and all rights and claims for damages that I may have against the Co-Op, host church, or any of their representatives, for injuries that may arise out of the program. Photos of my child may be used on the internet or in printed materials by KACHEA.

PROPERTY REPLACEMENT PLEDGE
I agree to be financially responsible for any and all property damage that may result from my child’s actions or mine while in attendance at the Co-Op or its functions.

PLEDGE OF COMMITMENT
I have read the Co-Op guidelines and agree to them. I agree with and have signed the KACHEA statement of faith and Code of Conduct.

By registering in the Co-Op I pledge to all of the other families involved that I will have my Co-Op duties as a priority in my life and will fulfill those duties to the best of my ability.

I HAVE READ AND UNDERSTAND THIS AGREEMENT AND HAVE WILLINGLY PLACED MY SIGNATURE BELOW AS EVIDENCE OF MY ACCEPTANCE OF ALL THE CONDITIONS MENTIONED.

SIGNED

Clear

Date

KACHEA CO-OP