CCS Athletics

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: ______________________________ ------------------------------------------------------------------------------------------------------------------------------------------------------ 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 ______________