The Cornerstone Christian School , 236 Main Street , Manchester , CT 06042
AUTHORIZATION FOR PARTICIPATION IN ATHLETICS Student Name : __________________________________ Address :________________________________________ Phone #: ________________________________________ Sport ( s ): ______________________
STATEMENT OF COMMITMENT
One of the goals of The Cornerstone Christian School ( CCS ) Athletic Department is to help teach the value of commitment and Godly behavior in the area of competitive sports . Paul admonishes us to “ finish the race .” By signing this form , the parent agrees to commit the child to the team for the season .
STATEMENT OF ASSUMED RISK
There are many benefits to participation in athletics ; however , there are also risks . Although CCS has attempted to provide safe facilities , good equipment , and qualified coaches , there is always a chance , despite these precautions , that an injury can occur . By allowing your child to participate in athletics , you are acknowledging the fact that you are putting him / her in a potentially injurious situation .
STATEMENT OF INSURANCE
In the event of any injury , during any aspect of a student ’ s participation in the CCS Athletic Program , IT IS THE RESPONSIBILITY OF THE PARENTS / GUARDIAN OR THEIR INSURANCE COMPANY TO PAY FOR MEDICAL EXPENSE , INCLUDING AMBULANCE FEES .
STATEMENT OF PHYSICAL HEALTH
Your child is required to have an annual doctor ’ s examination for participation in athletics . The last examination must occur after April 30 to be valid for the succeeding school year . If your child has the doctor ’ s permission to participate in multiple sports , please indicate that in the space provided above . If your child has any pre-existing medical conditions that could affect athletic participation , please explain on an attached sheet .
PERMISSION TO PARTICIPATE
I hereby state that I have read the above statements and under these conditions give permission for my child _____________________ , to participate in these sports : ________________________________________. I agree to hold The Cornerstone Christian School , its employees , and volunteers harmless for any claim or action that might arise on behalf of myself or my son / daughter other than for the willful , wanton , or reckless misconduct of Cornerstone , its employees or volunteers . I understand that my son / daughter will agree to obey the instruction of the Cornerstone coaches or staff of the sport and respect the rights of others .
Father or Guardian Signature _______________________________________ Date : _________________ Mother or Guardian Signature ______________________________________ Date : _________________
PERMISSION FOR EMERGENCY TREATMENT
If a medical emergency should arise and I cannot be reached , the Cornerstone coaches and staff have my permission to obtain any necessary emergency care for my child , ________________________________________. FATHER ’ S NAME ADDRESS IF DIFFERENT HOME PHONE # CITY , STATE , ZIP ADDRESS OF EMPLOYER
WORK NUMBER
MOTHER ’ S NAME ADDRESS IF DIFFERENT HOME PHONE # CITY , STATE , ZIP ADDRESS OF EMPLOYER
WORK NUMBER
PHYSICIAN & ADDRESS PHONE #
EMERGENCY CONTACT PHONE #
INSURANCE COMPANY POLICY #
ALLERGIES , SPECIAL CONDITIONS OR MEDICATIONS : _________________________________________________ SIGNATURE ________________________________________
DATE ______________
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