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.
  • Date Format: MM slash DD slash YYYY
  • GRACE ACADEMY POLICY: We, being the parent(s) or legal guardian(s) of the above named minor, do hereby appoint: (yourself, friend, or family):
  • 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, 2019 THROUGH MAY 30, 2020. 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.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: 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)