Parental Consent, Certification, and Medical Authorization For 2018
This form allows your child to attend and participate in Cornerstone events for the calendar year of 2018.
Email address *
Consent and Certification
I, the undersigned, being the parent or legal guardian of the child named above (the "child"), do hereby consent to the participation of my child in activities sponsored by Cornerstone Christian Church throughout the year 2018.
Child's Name (First and Last) *
Date of Birth *
MM
/
DD
/
YYYY
Home Address *
Parent/Guardian Name(s) *
Preferred Parent/Guardian Phone Number *
Work Phone Number
Insurance Company *
Policy # *
Group #
Other Emergency Contact (Name and Phone #) *
Is your child presently being treated for an injury or sickness or taking any form of medication for any reason? *
If yes please give details
Is your child allergic to any type of medication? *
If yes please give details
Does your child have any food allergies or require a special diet? If so please give details.
Does your child have any other allergies or medical conditions we should know about?
Can your child swim?
Medical Treatment Authorization
I understand that I will be notified in the case of a medical emergency involving my child. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary services in the event my child is injured or becomes ill. I understand that the church will not be responsible for medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.
I agree to notify the church in the event of any health changes that would restrict my child's participation in any normal youth or children's activities. I also understand that the adult supervisors reserve the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child.
Typing your name and filling in the date below will serve as your signature. *
Date of Signing *
MM
/
DD
/
YYYY
Please upload a copy or picture of both sides of your insurance card
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. - Terms of Service - Additional Terms