*REQUIRED* Medical Emergency Form

indicates a required answer

1. *

Parent Name:

2. *

Student(s) Names:


In the event of an emergency, KHHC will attempt to contact parents immediately. If parents cannot be reached, the emergency contact listed below will be notified. If necessary, students will be treated by emergency responders at parent’s expense.

  • Please state your name and phone number
  • Please list the name and phone number of your emergency contact.
  • Provide the name of each student with life threatening allergies and a brief list of what they are.

Please list any Life Threatening Allergies:

5. *

Emergency Contact Name and Phone Number: