KCC Net

Documents Home

Charters

Financial

Job Descriptions

Legal

Minutes

Policies

Google
Search for:



Download this form as an RTF document.

First AidD and Emergency Medical Treatment

Version dated: March 19, 2004

I recognize that there may be occasions where I may be in need of first aid or emergency medical treatment as a result of an accident or illness.  I hereby give permission for agents of KCC to seek and secure any medical treatment, including hospitalization, which may be deemed necessary and reasonable under the circumstances.  I agree to pay all fees and costs arising from such action to obtain medical treatment.  This permission for emergency medical treatment also includes minors under my control.

Dated: ____________________

Sign Name: __________________________________

Print name: __________________________________

Address:_________________________________________________
________________________________________________________________

Emergency Contacts

Medical Doctor________________________ Phone _____________________

Name____________________________________
Relation_______________________
Home Phone__________________ Other phone___________________

Name____________________________________
Relation_______________________
Home Phone__________________ Other phone___________________

                     

Medical History and Special Medical Needs


___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________