KC Health History Form

Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

School *

Grade *

Home Phone *

Student Cell Phone *

Cell Carrier *

Can recieve text message reminders about upcoming events, deadlines, and schedule changes *

Yes No

Parent/Guardian 1

Name *

First

Last

Relationship *

Cell Number *

Email *

Home Number *

Parent/Guardian 2

Name *

First

Last

Relationship *

Cell Number *

Email *

Home Number *

in case of emergency

Emergency Contact (Not Parent/Guardian 1 or 2) *

First

Last

Relationship *

Phone Number *

Children's health

List all medications *

Parent / Guardian E-Signature (Full name & DOB) *

Will student be responsible for own medication? *

Yes No

May student be given Tylenol/ibuprofen for headaches and/or minor injuries? *

Yes No

This health history is correct as far as I understand, and the person herein described, is free of potential health problems which might restrict his or her participation (except as noted). In the event I cannot be reached in an emergency, I hereby give permission to the physician, hospital, clinic selected by the youth leaders to treat, hospitalize, secure proper anesthesia, injections or surgery.

Online Health History Submission

Children/Youth Information

Parent/Guardian 1

Parent/Guardian 2

in case of emergency

Children's health