WHS Insurance Release Form

WHS Online Insurance Release Form

 INSURANCE RELEASE FORM

 Release to: Board of Education of Jefferson County, West Virginia

1. We, the undersigned parents/guardians of:*__________________________________________

2. Sport or Activity:*______________________________

 3. Check One:*

_________Hereby warrant to the Board of Education of Jefferson County that we have in force a health insurance policy which will reimburse said child for medical expenses which they may incur by reason of any damage or injuries sustained by them.   

_________DO NOT have in force such insurance but we warrant that we are financially able to pay any medical expenses for any injuries that may be incurred by said child during their participation in athletics in the schools of Jefferson County, West Virginia.   

 

4. Given under our hands on this date:*_____ / _____ / _____

5. Signature of Parent (Guardian):*_________________________________________

 6. Signature of Parent (Guardian):*_________________________________________

 Because of the dangers of participating in the above activity, I recognize the importance of listening to and following all of the coach's instruction and warnings regarding playing techniques, training methods, rules of the sport and other team rules. I also recognize the importance of reading and adhering to all written instructions and written warnings regarding playing techniques, training methods, rules of the sport and other team rules. I understand that all instructions and warnings, verbal and written, are incorporated by reference into this agreement and I hereby expressly promise to obey all such instructions and warnings given me by my coaches.

 7. Athlete:*____________________________________________

 8. Sport:*______________________________

 9.  Date:*_____ / _____ / _____

  

   

 

  Parental completion of this form also serves as permission for student participation in the athletic program and/or out of season conditioning.

 

 

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