Insurance Waiver

Insurance Waiver
Purpose: Every student athlete must present a completed Insurance Waiver or verification of school insurance in order to practice or take part in interscholastic athletics. This form is a statement from parents indicating they do not have school insurance.
IS NOT COVERED BY SCHOOLS INSURANCE
Print Athlete's Name
IT IS OUR UNDERSTANDING THAT HERITAGE CHRISTIAN SCHOOL, ITS ATHLETIC DEPARTMENT, AND ITS BOARD OF DIRECTORS WILL NOT ASSUME THE RESPONSIBILITY OR OBLIGATION FOR ANY MEDICAL BILLS OR DEBTS RESULTING FROM ANY INJURY TO THE ABOVE NAMED PLAYER WHILE PRACTICING OR PLAYING IN ANY PRACTICE SESSION, SCRIMMAGE, OR CONTEST.
Please check the appropriate space below
Name of Insurance Company
Policy Number
Signature of ParentLegal Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Parent/Legal Guardian

First NameLast Name
Street Address
City State Zip
Telephone
Format: (000) 000-0000.
Should be Empty: