KCC: First Aid and Emergency Medical Treatment


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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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