Insurance Verification Form - All Sports - 2015/16 printable pdf download

Insurance Verification Form - All Sports - 2015/16

NORTHERN BEDFORD COUNTY SCHOOL DISTRICT

INSURANCE VERIFICATION FORM – ALL SPORTS – 2015/16

Dear Parent:

Since July 1, 2014, the school district discontinued the purchase of additional student athletic

insurance and is requiring the parent to provide proof of coverage prior to the student’s

participation in the athletic and high school band program. Board policy says that effective

July 1, 2015, all students prior to participation will have completed the PIAA Physical Evaluation

form and have on file the insurance verification form. Proof of medical insurance must be

provided to approve participation in the extra-curricular athletic and band programs.

I certify that I will be responsible for any needed medical services arising because of my

son/daughter/s participation in Interscholastic Athletics or high school band by covering

such through my personal medical insurance. I certify that I have attached a copy of

the child’s medical card which shows the name and policy of the insurance company. I

also certify that I will notify the school district if this policy changes throughout the

2015/16 school year and that coverage will be maintained as such.

Name and policy number of your Insurance Company

Student’s Name________________________________ Grade in School _____________

Address_______________________________________ Phone ____________________

Anticipated Program Student participating in_________________________________________

I hereby acknowledge that if this information changes in the course of my student’s

participation in the above noted extracurricular activity that I will inform the district as soon as

possible.

___________________________________

________________

Signature of Parent/Guardian

Date

Insurance Verification Form - All Sports - 2015/16