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KCC: First Aid 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
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
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