The Cornerstone Christian School 236 Main Street , Manchester , CT 06042 Phone : 860-643-0792 MEDICAL AUTHORIZATION FOR ATHLETIC PARTICIPATION ( To be completed by parents / guardians )
Name : _____________________________________ Grade : ________ Date of Birth : ____________ Age : _____________ Address : ____________________________________________________________________________________________ Father ’ s Name : ____________________________________________ Work Phone : _______________________________ Mother ’ s Name : ___________________________________________ Work Phone : _______________________________ Home Phone : _________________ Emergency Contact & Phone No .: ___________________________________________ Family Doctor : ____________________________________________ Office Phone : _______________________________
INSURANCE STATEMENT
Our son / daughter will comply with the specific insurance regulations of The Cornerstone Christian School and the Manchester Church of the Nazarene . Family Insurance Company : ____________________________________________________________________________ Signature of Parent / Guardian : ___________________________________________________________________________
HISTORY |
YES |
NO |
YES |
NO |
Have you had : Fainting |
Do you now have Blurred Vision |
Diphtheria |
Headaches |
Scarlet Fever |
Fainting |
Rheumatism |
Convulsions |
Poliomyelitis |
Backaches |
Pneumonia |
Pounding of Heart |
Asthma |
Shortness of Breath |
Diabetes |
Frequency of Urination |
Heart Disease |
Cough |
Kidney Disease |
Nosebleeds |
Tuberculosis |
Frequent Sore Throats |
Jaundice |
Stomach Pains |
Rupture |
Blackouts |
Explain all ‘ Yes ’ Responses :_____________________________________________________________________________ |
____________________________________________________________________________________________________ |
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