FATHER’ S NAME ADDRESS IF DIFFERENT CITY, STATE, ZIP ADDRESS OF EMPLOYER
MOTHER’ S NAME ADDRESS IF DIFFERENT CITY, STATE, ZIP ADDRESS OF EMPLOYER
PHYSICIAN & ADDRESS
ADDITIONAL EMERGENCY CONTACT PERSON
EMERGENCY CONTACT INFORMATION PLEASE PRINT
HOME PHONE CELL PHONE WORK NUMBER
HOME PHONE CELL PHONE WORK NUMBER
PHONE PHONE
INSURANCE COMPANY POLICY #
MEDICAL TREATMENT CONSENT( To be completed by parents)
I, ______________________________________, the parent or guardian of _______________________________ recognize that as a result of athletic participation, medical treatment on an emergency basis may be necessary.
In the case of an accident or serious illness, the school will attempt to contact me. If needed, I understand that my child will be transported to the nearest hospital for emergency care and treatment. I do hereby consent in advance to such emergency care, including hospital care, as may be deemed necessary under the then existing circumstances and to assume the expenses of such care.
Although the school desires to provide a safe and enjoyable time for all students, accidents can still happen. I / We understand that there are risks / dangers involved with participation in off-campus trips and their associated activities. In consideration of my child being allowed to participate in this event, I / we agree to assume responsibility for those ordinary and reasonable risks associated with the travel and activities. I / We agree to release and to hold harmless The Cornerstone Christian School( a ministry of the Manchester Church of the Nazarene), its affiliated organizations, employees, agents, and representatives, including volunteer and other drivers, from any and all claims, including any claims of negligence, arising from my child ' s participation. This release agreement does not apply to claims of intentional( criminal) misconduct or gross negligence by the school, its employees, or volunteers. If such circumstances are proved in a court of law, I / we acknowledge and agree that the school can assume no financial liability beyond its actual liability insurance policy in force.
__________________________ _______________________________ _______________________
( Please print Parent / Guardian name)( Parent / Guardian Signature)( Date)
Date: _____________________
_______________________________________________________________________ Signature of Parent or Guardian