The Cornerstone Christian School 236 Main Street, Manchester, CT 06042 Phone: 860-643-0792 CCS Sports Medical Form
( This page must be completed by parents / guardians.)
Name: _______________________________ Grade: ________ Date of Birth: ____________ Age: _____________
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:_____________________________________________________________________________ ____________________________________________________________________________________________________ ALLERGIES, SPECIAL CONDITIONS OR MEDICATIONS: _________________________________________________
Date: _____________________
_______________________________________________________________________ Signature of Parent or Guardian
The next page must be completed by a physician.