2022-2023 NEW FAMILY APPLICATION | Page 28

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 : ___________________________________________________________________________

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