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Student Commitment to Excellence Contract and Tuition Agreement
Name
First Last
Financial Commitment
I promise to pay my tuition in full and communicate with the Kanakuk Institute about my financial situation.
- Yes
- No
I understand that a $250 non-refundable deposit is required to reserve my spot at the Kanakuk Institute. This will go toward my tuition.
- Yes
- No
I understand if I would like the $7,500 scholarship I am committing to 5 hours of campus work per week (2 hours in dining hall and 3 hours on campus).
- Yes
- No
I will fulfill this scholarship opportunity to the best of my ability and recognize if I fail to fulfill my duties my scholarship will be reduced based on the number of hours not completed.
- Yes
- No
If for any reason I choose not to complete the program after the start date in September, I understand I am still responsible to pay the full tuition amount.
- Yes
- No
I understand that if my tuition is not paid completely by graduation date that I will pursue a loan and that the Institute reserves the right to charge interest on any outstanding debt (currently 5% annually and subject to change without notice).
- Yes
- No
Select the appropriate box below. Every student will benefit from the the $7,500 work study scholarship.
Please check one.
- Single Student - Work Study Scholarship
- Married Students
I understand the commitments I am making and promise to follow through on them.
Full Name*
First Middle Last
Signature*
Health, History, and Emergency Contact Info
Email Address
Date of Birth
Date Format: MM slash DD slash YYYY
Emergency Contact Info
Name Relationship Daytime Phone Cell Phone

Please list at least two emergency contacts.
Use the '+' button to add additional rows.
HEALTH DISCLOSURE STATEMENT: For the protection of your safety and the well being of all the students at the Kanakuk Institute, FULL disclosure must be made regarding any PHYSICAL, SOCIAL, AND/OR 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 crucial to our ability to provide a supportive, safe and healthy learning environment for you. Please make a copy of this form and keep for your records.
Allergies
Check those that apply to you:
- I am allergic to peanuts and/or nuts.
- I am allergic to these substances (mold, dust, insect stings, other)
- I have allergies to some types of drugs.
Please provide details about any allergies.
Chronic Concerns
Check all categories that pertain to you and provide information about supportive health care.
- Anorexia/Bulimia (Eating Disorders)
- Anxiety
- Asberger's / Downs / Autistic
- Asthma (even if only occasionally uses inhaler)
- Bi-Polar/Psycho/Social Disorder
- Bleeding Disorders
- Celiac Disease
- Depression
- Diabetes
- Eczema
- Hearing/Visually Impaired
- Knee Problems (total knee replacement, ACL, etc.)
- Muscular Coordination
- Oppositional Behavior Disorder
- Special Diet
- Seizure Disorder
- Suicidal Tendencies
- Tourettes Syndrome
What Year Diagnosed with Diabetes?
Insulin Pump*
- Yes
- No
Please provide details about any items checked above.
Prescription Medication
Name of Medication Reason for Taking Dose Taken Time Taken Each Day

Please provide complete information on any medication taken on a regular basis.
Use '+' to the right to add additional rows.
- I do not take any medications on a regular basis.
Medical Insurance Carrier
Medical Insurance Policy #
Student Health Questionnaire
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!
List and discuss any special needs you may have as well as other physical or psychological conditions (other than those noted on the Health Form):
Are there any special concerns you have regarding your year at the Institute?
Are there any pre-existing conditions that you have that may hinder your ability to take part in athletic activities at the Institute?
Is there any medical condition that you have that you would want to ensure that we were aware of?
Have you been hospitalized or had surgery for anything in the past 2 years; please be specific
Have you ever had or been treated by a Doctor for any of the following conditions:
- Ears/Nose/Throat
- Eyes
- Heart
- Lungs
- Abdomen
- Skin
- Neck
- Back
- Shoulder/Arms
- Elbow/Forearms
- Wrist/Hand
- Hip/Thigh
- Knee
- Leg/Ankle
- Foot
- Heart Disease
- Stroke
- High Blood Pressure
- Cancer
- Diabetes
- Faintness during exercise
- Dizziness during and after exercise
- Shortness of breath
- Muscle Weakness
- Joint/Pain Stiffness
- Heart Murmur
- Irregular Heart Beat
- Seizures
- Orthopedic Injury
- Weight Loss/Anorexia
- Frequent Ear Infections
- Hearing Visual Disorder
- Migraine Headaches
- Orthopedic Disorder
- Eneuresis
You checked Orthopedic Disorders, could you please explain further?
Do you have any restrictions on your activities?
- Yes
- No
Activities restricted by whom?
What kind of activities are you restricted from?
Have you been hospitalized in the last year?
- Yes
- No
Please explain the reason for your hospitalization(s)
AUTHORIZATION FOR HEALTH CARE
To the best of my knowledge, all information provided on this form is accurate and complete. I am in good health and able to participate in all Kanakuk Institute activities. I hereby give my permission to the physician selected by the Health Services Director and/or Institute President to order X-rays, routine tests, and treatment. In the event that I am incapacitated and my emergency contacts cannot be reached in an emergency, I hereby give my permission to the physician selected by the Health Services Director and/or Institute President to hospitalize, secure proper treatment, and order injections and/or anesthesia and/or surgery.
Financial Deposit of $250
Deposit
Price: $250.00
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Total
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
NOTE: To avoid the duplicate charges, please press the submit button only once.
Signature