KO Bros Sports Academy Medical Release Form Section I: Student Athlete Information Student Athlete's Full Name * First Name Last Name Student Athlete Date of Birth (DOB) * MM DD YYYY Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Name on Policy Policy Number Insurance Provider Section II: Student Athlete Medical History 1. Are there any injuries requiring medical attention? * Yes No 2. Are there any past surgeries or scheduled surgeries? * Yes No 3. Is the participant currently under the care of a medical practitioner? * Yes No 4. Is the participant currently taking any medications? * Yes No 5. Does the participant have any allergies (penicillin, bee stings, etc)? * Yes No 6. Does the participant have asthma/require the use of an inhaler? * Yes No 7. Is the participant diabetic/require medication for diabetes? * Yes No 8. Does the participant currently require medication? * Yes No 9. Does/has the participant have/had seizures? * Yes No 10. Does the participant wear glasses or contact lenses? * Yes No 11. Does the participant wear a brace or other medical support device? * Yes No 12. Does the participant have physical limitations or medical conditions? * Yes No If you answered yes to any of the above questions, please provide the question number and an explanation in the following space: Section III: Student Athlete Allergies a. Does the student athlete have any known allergies? * Yes No b. If yes, please specify the type of allergy (check all that apply): Food Allergies Medication Allergies Environmental Allergies Insect Allergies Other c. Please list specific allergens: d. Describe the allergic reaction (symptoms): e. Does the participant carry an EpiPen or other emergency medication? Section IV: Dietary Restrictions a. Does the student athlete have any dietary restrictions? * Yes No b. If yes, please specify the type of dietary restriction (check all that apply): Gluten-Free Dairy-Free Nut-Free Vegetarian Vegan Kosher Halal Other c. Please provide details about the dietary restrictions: I hereby certify that this information is accurate to the best of my knowledge. I understand that this medical authorization may be voided in the event of injury, illness or accident and my child may not be cleared for participation at such time. Furthermore, I hereby acknowledge that it is my responsibility to inform my child’s organization official in writing if there is any change in the medical condition of my child. I also understand that is my responsibility to obtain written permission from my child’s physician on official medical stationary in order to seek permission for my child to resume participation after any and all such injury, illness or accident. Parent / Guardian's Full Name * First Name Last Name Parent / Legal Guardian Confirmation * By checking this box, I confirm that I am the biological parent and/or legal guardian of the student-athlete listed above, and that I am authorized to execute this form on behalf of my student-athlete and my family. Review and Approval Confirmation * By checking this box, I confirm that I have carefully read and fully understand the KOA Medical Release Form, and I expressly agree to all terms, conditions, and authorizations contained herein. Parent / Guardian's Signature * Date * Input today's date MM DD YYYY Thank You!Thank you for completing the KOA Medical Release Form. Your submission has been received successfully. We appreciate your feedback and look forward to seeing your student-athlete at KOA in the near future.KO Bros Sports Academy (KOA)
