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 : ___________________________________________________________________________
Have you had : Fainting Diphtheria Scarlet Fever Rheumatism Poliomyelitis Pneumonia Asthma Diabetes Heart Disease Kidney Disease Tuberculosis Jaundice Rupture
HISTORY YES NO YES NO Do you now have Blurred Vision Headaches Fainting Convulsions Backaches Pounding of Heart Shortness of Breath Frequency of Urination Cough Nosebleeds Frequent Sore Throats Stomach Pains Blackouts
Explain all ‘ Yes ’ Responses :_____________________________________________________________________________ ____________________________________________________________________________________________________
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 and further recognize that The Cornerstone Christian School personnel may be unable to contact me for my consent for emergency medical care ; 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 .
Date : _____________________
_______________________________________________________________________ Signature of Parent or Guardian
please see reverse side for Physicians portion