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Lakewood City School Athletic Department

Signature and Insurance Verification Form

Student Name__________________________________________Grade_________School Year___________________

Address_______________________________________________Phone_________________________________

School ( ) Lakewood HS ( ) Garfield MS ( ) Harding MS

ACKNOWLEDGEMENT OF RISK

Risk in sports is a topic, which has received great publicity recently. All human activity, including sports, has a potential for causing injury to

individuals. Sports injuries can range from simple cuts and bruises to serious conditions such as fractures and severe sprains possibly requiring

surgery to catastrophic occurrences which include eye injuries, neck and back injuries with resulting paralysis, and although rare, death.

I acknowledge the fact that the risk of injuries detailed above is present in the sports offered in the Lakewood City Schools. I grant my child

permission to assume these risks with the understanding that the Lakewood City School’s coaches will do everything in their power to reduce the

injury potential to my/our child.

Signed________________________________________________________________________________ Date__________________________________ __________________

Signature of parent or guardian

INSURANCE VERIFICATION

I the parent or guardians of _______________________________________________________________________________________________________________ have

Insurance with ___________________________________________. Policy number_______________________________________________________that will pay the

medical or surgical expenses that result from any injury, major or minor, that the above-named student may receive as a result of practicing or

performing in athletics at Garfield or Harding Middle School / Lakewood High School.

Since I, the parent or guardian of the above-named student, have an insurance policy which will provide adequate financial coverage for any type

injury or injuries or whatever might result there from, I, the parent or guardian agree to release the Lakewood City School System or any part thereof,

from any obligation as pertains to financial responsibility in these matters for the school year or any period of the time thereafter.

Signed________________________________________________________________________________ Date___________________________________________________ _

Signature of parent or guardian

Only fill out bottom portion if you have NO insurance

INSURANCE WAIVER

Only fill out if you have No Insurance

I, the parent or guardian of_______________________________________________________________________do hereby acknowledge that an accident insurance

policy is not in force for our son/daughter that will pay the medical or surgical expense that results from any injury, major or minor, that the above-

named student may receive as a result of practicing or performing in athletics at Garfield or Harding Middle School / Lakewood High School.

Since I, the parent or guardian of the above-named student do not have an insurance policy which will provide ad\equate financial coverage for any

type injury or injuries or whatever might result there from, I, the parent or guardian agree to release the Lakewood City School District or any part

thereof, from any obligation as pertains to financial responsibility in these matters for the school year or any period of the time thereafter.

Signed________________________________________________________________________________ Date_________________________ ___________________________

Signature of parent or guardian

Signature And Insurance Verification Form - Lakewood City School Athletic Department

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