Athletic Permission And Hold Harmless Form (Page 2 of 2) in pdf

PROOF OF ACCIDENT/INJURY INSURANCE

Student Name________________________________________________________________________________________________

Last

First

Middle Initial

Address_______________________________________________________________

Phone______________________________

Family Physician________________________________________________________

Phone______________________________

Hospital_____________________________________________________________________________________________________

I do not wish to enroll my son/daughter in the student accident insurance plan offered by the School District.

1. My child is insured by ________________________________________________________________________

Insurance Carrier

2. Policy # or Group Plan # ___________________________ provides at least $10,000 insurance protection for medical and

hospital expenses resulting from accidental bodily injuries incurred while participating in, practicing for, and traveling to

and from athletic events. I shall maintain the above coverage during the school year and will notify the school if the

coverage terminates or if the insurance carrier is changed.

3. To the best of my knowledge my child has no physical problems that would keep him/her from participating in this after

school sports program.

I certify under penalty of perjury that the above information is true and correct.

________________________________________

__________________________________________

Parent/Legal Guardian Signature

Date

____________________________________________________________________________________________________________

TRANSPORTATION

I understand that the ____________________________________ School District

will,

will not provide transportation to

and from athletic events that are not held on the school site. I also understand that my child must be released to a parent upon

return to the campus unless I have indicated that he/she has my specified permission to walk home.

PLEASE SIGN THE APPROPRIATE PART OF THE FORM BELOW WHICH SPECIFIES EITHER PERMISSION FOR YOUR CHILD TO WALK

HOME, OR AGREEMENT THAT YOU WILL PICK THE CHILD UP PROMPTLY FROM OUR __________________________________

CAMPUS AFTER PRACTICES OR GAMES. COACHES WILL KEEP PARENTS INFORMED ABOUT PRACTICE AND GAME ENDING TIMES.

My child: ______________________________________________________ has my permission to walk home from our junior high

campus after practices and games.

I agree to pick up my child _________________________________________________________ after practices or games promptly

from our junior high campus. I understand that repeated late pick-ups may result in my child being dropped from the team.

________________________________________

__________________________________________

Parent/Legal Guardian Signature

Date

Athletic Permission And Hold Harmless Form Page 2