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: ______________________________
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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, ________________________________________________.
PLEASE PRINT
FATHER’S NAME
ADDRESS IF DIFFERENT
CITY, STATE, ZIP
ADDRESS OF EMPLOYER
MOTHER’S NAME
ADDRESS IF DIFFERENT
CITY, STATE, ZIP
ADDRESS OF EMPLOYER
HOME PHONE #
WORK NUMBER
HOME PHONE #
WORK NUMBER
PHYSICIAN & ADDRESS PHONE #
EMERGENCY CONTACT PHONE #
INSURANCE COMPANY POLICY #
ALLERGIES, SPECIAL CONDITIONS OR MEDICATIONS: _________________________________________________
SIGNATURE ________________________________________ RELATIONSHIP _______________ DATE ______________