Parent Release Form - Grace Academy

Date
MM slash DD slash YYYY
I. TRANSPORTATION PERMISSION*
- Drive his/her own car to/from athletic practices/games.
- Ride with student drivers to/from athletic practices/games.
- Ride with other parent to/from athletic practices/games.
- Ride with coach/staff to/from athletic practices/games.
Applicant has permission to (check as many as apply to your student):
If your child needs medical, dental, health, or hospital services, you as parent must give permission. It's the law. This is a legal document. With it, you may appoint relatives, friends, teachers, coaches, anyone over 18 years of age, to be responsible for your child when you are away from them.
A parent must read and sign the Parent Concussion Statement at the beginning of each sport’s season, as advised by the Centers for Disease Control. GRACE ACADEMY POLICY: ALL ATHLETES MUST BE COVERED BY PERSONAL MEDICAL INSURANCE TO PARTICIPATE IN THE ATHLETIC PROGRAM AT GRACE ACADEMY.
Name of Minor
First Last
Birth Date
MM slash DD slash YYYY
Identify allergies or special conditions
GRACE ACADEMY POLICY: We, being the parent(s) or legal guardian(s) of the above named minor, do hereby appoint: (yourself, friend, or family):
Name
First Last
Phone 1
Phone 2
Address
Street Address Address Line 2 City State ZIP Code
AND: Grace Academy Staff and Coaching Staff PO Box 2553, Matthews, NC 28106 (704) 234-0292
AUTHORIZATION
TO ACT IN MY/OUR BEHALF IN AUTHORIZING UNEXPECTED MEDICAL, DENTAL, SURGICAL CARE AND HOSPITALIZATION FOR THE ABOVE NAMED MINOR DURING THE PERIOD OF MY/OUR ABSENCE FROM: AUGUST 1, 2022 THROUGH MAY 30, 2023. The parent or legal guardian set forth in this form does hereby agree to hold harmless the person appointed and a physician providing treatment from and against any and all loss, cost, damage, or expense of any kind arising out of or in connection with that person's or physician's acting in reliance upon the authorization set forth herein, with the exception of actions which amount to gross negligence. The physician shall not be relieved on the basis of this authorization for liability for negligence in the diagnosis and treatment of a minor. THIS DOCUMENT SHALL BE PRESENTED TO A PHYSICIAN, DENTAL, OR APPROPRIATE HOSPITAL REPRESENTATIVE AT SUCH TIME AS UNEXPECTED MEDICAL, DENTAL, SURGICAL CARE OR HOSPITALIZATION MAY BE REQUIRED.
Parent/Guardian Signature
Parent/Guardian Signature
Address
Street Address Address Line 2 City State ZIP Code
Date
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State ZIP Code
Date
MM slash DD slash YYYY
Witness Signature (other than minor)
Witness Signature (other than minor)
Address
Street Address Address Line 2 City State ZIP Code
Date
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State ZIP Code
Date
MM slash DD slash YYYY
INSURANCE
HOSPITALIZATION COVERAGE FOR ABOVE NAMED MINOR: (All athletes MUST have medical insurance to participate in the athletic program at Grace Academy)
Insurance Co.
I.D. pr Group No.
Name of Insured
SSN or Insured
Date
Athlete SSN
Family Physician
Physician's Phone #
Physician's Address
Street Address Address Line 2 City State ZIP Code
UPLOAD FRONT AND BACK OF INSURANCE CARD
Max. file size: 128 MB.

AUTHORIZATION

INSURANCE