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Kentucky Sponsor/Adult Medical Release Form

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Kentucky Sponsor/Adult Medical Release Form
Kentucky Sponsor/Adult Medical Release Form
EMERGENCY AUTHORIZATION: I hereby give permission to the medical personnel attending to my treatment to order x-rays,
routine tests and treatment. In the event of an emergency, I hereby give permission to the attending physician to hospitalize, secure
proper treatment for, and to order injection and/or anesthesia and/or surgery.
I authorize Kentucky Christian University and its employees or agents to take photographs, video recordings, and audio record-
ings of me and/or my child. I agree to my image, voice and/or likeness being used in all forms of print and electronic media
publications and/or video productions for purposes related to the University, including research, education, publicity, market-
ing, and promotion of programs for the University. I agree to hereby release, hold harmless, and discharge KCU, its ofcers,
agents, and employees from and against any and all claims, actions, or causes of action, liability, and demands whatsoever
beyond the control of, and without the fault or negligence of Kentucky Christian University.
Signature ___________________________________________________________________________________Date__________________
Witness_____________________________________________________________________________________Date__________________
Sponsor Information
Last Name_______________________________________ First Name_______________________________ MI______ Sex_____
Home Address______________________________________________________________________________________________
City________________________________________________________ State_________ Zip______________________________
Home Phone (________) ___________________________
Emergency Phone (_______)_____________________________ Relationship__________________________________________
County of Residence________________________ Birthdate________________ Age_____
Church Name_______________________________________________City________________________________State________
Insurance Company Information
Complete Name of Insurance Company______________________________________________________________________________
Policy Holder Name_______________________________________________________________________________________________
Group #___________________________________________ Group Name___________________________________________________
Address of Insurance Company_____________________________________________________________________________________
City________________________________________________________ State_________ Zip_______
________
______________________
(Continued next page)
Please staple a photocopy of BOTH SIDES of your medical
Insurance card to this form and return it to your team sponsor.
Sponsor must make a copy of completed Permission form
and the Individual Code of Conduct form. Keep a copy for
your records and turn the original in to the
KCU Bible Bowl Tournament ofce on day of registration.
Please staple a photocopy of BOTH SIDES of your
medical Insurance card to this form and return it to
your team sponsor.
BIBLE BOWL SPONSORS DON’T FORGET: Please have copies of all registration forms
made before arriving. Originals are for KCU records. Copies are for your records.
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Sponsor/Adult Medical Release
Kentucky
Christian
University
Kentucky Sponsor/Adult Medical Release Form
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