For your safety and the well being of all the students at the Kanakuk Institute, FULL disclosure must be made regarding any PHYSICAL, SOCIAL, AND PSYCHOLOGICAL CONDITIONS. Failure to do so may result in your discharge from the program and the forfeiture of your tuition. Disclosure of health history is cruicial to our ability to provide a supportive, safer, and healthy learning environment for you. 

Please note this information will be made available ONLY to those who will be working directly with your care. This information is to help us assist you in having the very best experience possible!

To the best of my knowledge, all information provided on this form is is accurate and complete. I represent that I am in good health and able to participate in all Kanakuk Institute activities. Should the need arise, I give my permission to Kanakuk Institute staff, employees, or designees to call emergency responders or transport me to a healthcare provider selected by KI to secure medical treatment. In the event I am incapacitated, and my emergency contacts cannot be reached in an emergency, I hereby authorize the medical provider selected by KI to provide treatment which a physician, in the exercise of his/her best judgment, deems advisable and necessary for my well-being including, without limitation, to hospitalize, order injections, diagnostic tests, or anesthesia and/or surgery.