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Medical Release Form

* indicates a required answer.

1. *

Student's Name:

2. *

Grade:

3. *

Birthday (mm/dd/yy):

4. *

Sport(s):

In the event of an emergency occurring involving my son/daughter while at a Cornerstone Family School sponsored activity, I grant permission to the coaches to take whatever action necessary to ensure my son/daughter receives proper medial attention.

5. *

Home Phone:

6. *

Business Phone:

7.

Cell Phone:

8. *

Mailing Address:

Person to be notified, other than parent or guardian, in an emergency:

9. *

Name:

10. *

Phone Number:

11. *

Family Doctor:

12. *

Phone Number:

13. *

Insurance Company:

14. *

Policy #:

15. 

Please list any medical conditions that we need to be aware of:

16. 

Please list any medications that your child is currently taking and any known allergies:

17. *

Parent Signature:

18. *

Date:

By entering your name, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this form.

I certify that my child, named above, is physically capable and able to fulfill requirements needed to participate in the above named sport. By signing this form, I release all obligations for the medical treatment of my son/daughter in the event of illness or injury during any sport related activity when either parent cannot be reached. If there is any physical or medical reason why he/she should not participate fully, Cornerstone Family School requires a doctor's release. Furthermore, Cornerstone Family School is not liable for any injury incurred during the sport season.