Athletic Emergency Contact and Insurance Form

Athletic Emergency Contact and Insurance Form
Important Notice
North Lakes Academy District 4053 does not provide medical insurance for accidental injuries suffered by students on school property or at school sponsored activities. This includes any accidental injuries suffered during physical education activities. These types of injuries MUST be covered by your family medical insurance or by an individual policy that you would provide to your student. If you wish to provide individual accident insurance for your student(s), you must make arrangements for that coverage with your own insurance company. The School District cannot assume liability for accidental student injuries that occur during the school day or at school-sponsored activities.
NLA Emergency Contact and Insurance Information
Sport(s):
Student Name:
Birthdate:
Gender:
Grade:
Address:
City:
State:
Zip:
Home Phone Number:
Parent(s) Name:
Daytime Phone:
Parent(s) Name:
Daytime Phone:
Primary Physician:
Physician Phone:
Primary Insurance Company:
Insurance Company Phone:
Policy Holder’s Name:
Group ID:
Policy Number:
I have read the NLA/MSHSL Rules On-Line:

NOTE: It is the responsibility of the parent and the student to notify a coach before the season begins of any pre-existing medical condition which may require emergency response during practice or play (diabetes, epilepsy, asthma, bee sting allergy, etc.)
Acknowledgment of Non-Coverage by NLA School District
I / We have read the notice on this form and understand that North Lakes Academy does not provide insurance coverage for accidental student injuries suffered during the school day or at school-sponsored activities. This includes any accidental injuries suffered while participating in physical education activities. I / We further understand that we are responsible for providing any needed or desired medical insurance-coverage for our student(s).
Parent/Guardian Signature:

Clear
Date

Month Day Year
Date
Consent for Emergency Care and Treatment
I/ We understand that every attempt will be made to notify me/us or the person indicated below in the event my child is injured. In the event notification is not possible, I / We do herby agree to give consent for appropriate emergency care medical care to be provided for, at my/our expense:
Parent/Guardian Signature:

Clear
Date

Month Day Year
Date
Emergency Contact Person (other than parent/guardian):
Emergency Contact Phone:
Relationship to Participant
Should be Empty:

Athletic Emergency Contact and Insurance Form

Important Notice

NLA Emergency Contact and Insurance Information

Acknowledgment of Non-Coverage by NLA School District

Consent for Emergency Care and Treatment