KDO Academy Medical Form

Form Status:

KDO Medical Authorization and Release Form:

Submit one per Student

Name of the Student:*

First NameLast Name

Birth Date*

MonthDayYear

Parents' Name:*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number:*

Area CodePhone Number

Cell Phone #1:

Area CodePhone Number

Cell Phone #2:

Area CodePhone Number

Emergeny Contact information:

Emergency Contact:*

First NameLast Name

Phone Number*

Area CodePhone Number

Cell Phone:

Area CodePhone Number

Alternate Contact:

Alternate Contact:

First NameLast Name

Phone Number

Area CodePhone Number

Cell Phone:

Area CodePhone Number

Family Physician:*

Physician Phone Number:*

Preferred Hospital:*

If you have medical insurance, your carrier will be billed for medical charges in

case of illness or injury while the above named is at KDO Academy.

Please complete info below:

Insurance Company:*

Primary Insured's Name:*

First NameLast Name

Policy Number:*

Insurance Phone #:*

Area CodePhone Number

Conditions requiring medications/or medical attention:

Details of Allergies:

In the event that I cannot be reached in a timely manner, in an emergency, I hereby give my permission to KDO Academy to obtain emergency medical care as deemed appropriate and/or necessary at the discretion of Genesis Church and/or KDO Academy. I also authorize them to administer medical aid as required for illness or injury under physician’s orders. I hereby authorize the staff of KDO Academy to act on my behalf in case of an emergency. I understand that I take full financial responsibility for any/all treatment.

My signature below serves as a medical release.

I realize that unanticipated injury and/or unexpected illness may arise during and associated with KDO activities. I voluntarily agree to accept any and all risks of injury/illness arising from these activities. I hereby agree to allow the above named to participate in all activities associated with KDO Academy.

Genesis Church and/or KDO Academy, its agents and all pastors, teachers, tutors, assistants shall not be held liable for any injury, personal injury, damage, loss, or accident which may occur as a result of my child’s participation in any event, class, or activity associated with, held by, or sponsored by KDO Academy.

Policy Agreement:*

I read this and agree with above

I understand a typed and submitted form is considered 'signed'.

Agreed by Parent:*

First NameLast Name

Today's Date:*

Date

E-mail Address:*

KDO HS/Bridge Medical Form