The Cornerstone Christian School 236 Main Street, Manchester, CT 06042
FAMILY AUTHORIZATION FOR PARTICIPATION IN ATHLETICS A separate physician’ s clearance is required.
Student’ s Name: __________________________________
School Year: 20 ____ to 20 ____
Grade: ________ Circle one: CCS or Homeschool Date of Birth: ____________ Age: _____________
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.
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: ___________________________________________________________________________
STATEMENT OF PHYSICAL HEALTH
Your child is required to have an annual doctor’ s examination for participation in athletics( within 12 months of beginning the sport.) You must submit medical clearance from a physician with a form dated after July 1 of the current school year. If your child has any pre-existing medical conditions that could affect athletic participation, please explain on an attached sheet.
ALLERGIES, SPECIAL CONDITIONS OR MEDICATIONS: _________________________________________________ ____________________________________________________________________________________________________
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.
Parent or Guardian Signature: _____________________________________________ Date: _______________________