KDO Academy Medical Form

Form Status:

KDO Medical Authorization and Release Form:

Submit one per Student

Name of the Student:*

First NameMiddle NameLast Name

Birth Date*

MonthDayYear

Student age*

Parents' Name:*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone #1:*

Area CodePhone Number

Cell Phone #2:

Area CodePhone Number

Emergency Contact information:

First Emergency Contact:*

First NameLast Name

Emergency Contact #1 Cell Phone:*

Area CodePhone Number

Relationship to student; ie Grandma, Aunt, etc.*

Second Emergency Contact:

First NameLast Name

Emergency Contact #2 Cell Phone:

Area CodePhone Number

Relationship to student; ie Grandma, Aunt, etc.

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:

Medical Consent Form:

I hereby give my permission to KDO Academy staff to obtain and coordinate emergency medical care as deemed appropriate and/or necessary at the discretion of KDO Academy and/or Genesis Church. I also authorize the named organizations to administer emergency medical aid as required for illness and/or injury under a medical professional's orders. I hereby authorize the staff of KDO Academy to act on my behalf in case of an emergency, until the time that I can be reached. I hereby accept full financial responsibility for transportation and any/all treatment in the event such action is necessary.

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.

I hereby release or hold harmless KDO Academy and/or Genesis Church, any staff and all pastors, teachers, tutors, assistants from responsibility and liability 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.

My signature below serves as a medical release for the current academic year.

Policy Agreement:*

I read this and agree with above

Signature*

Agreed by Parent:*

First NameLast Name

Today's Date:*

Date

E-mail Address:*

KDO HS/Bridge Medical Form