KCC Physical Exam for Health Career Students

KCC Physical Exam for Health Career Students
TO THE STUDENT: Placement in a clinical/lab within a health career program is conditional in that you must be physically capable and emotionally stable to perform the essential functions required in the specific program with or without reasonable accommodation, and be free from communicable diseases in the opinion of your physician. A medical examination by a legally qualified healthcare provider is required. The examination must be complete and on file in the Health Careers Division prior to the first day of classes. You must submit documentation of titer results and immunizations with this physical exam form. Physicals cannot be older than four months from your first day of classes.
Name
First and last name
Date:

MonthDayYear
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City:
Phone number:
Enter a valid phone number including area codeFormat: (000) 000-0000.
Date of birth:

MonthDayYear
Age:
Student ID number:
Enter your KCC student ID number
MaleFemale
Notify in case of emergency: Name
First and last name of emergency contact
Notify in case of emergency: Phone number
Phone number of emergency contactFormat: (000) 000-0000.
EMT-BasicParamedicMedical Laboratory TechnologyPhysical Therapist AssistantPhlebotomyRadiographyRespiratory Therapist
REV. 10/2021
Should be Empty: