Insurance Waiver Form

NORTH HILLS SCHOOL DISTRICT

INSURANCE WAIVER FORM

Name:___________________________________Age:_________________Birth

Date___________ Sport:____________________________________Grade:____________

Insurance Waiver and Release Form

Dear Parent:

Your child has indicated an interest in participating in the North Hills Athletic Program. We know that it is your wish as well as ours that every precaution be taken to protect our students from injury. We do our utmost to promote this by proper training, by the use of protective equipment, by supervising all activities, and encouraging good safety habits.

Despite our efforts, accidents do happen occasionally in athletics as elsewhere. The school is not legally liable for medical or hospital expenses resulting from athletic injuries incurred in interscholastic sports, but we certainly want to do our part to obtain the best possible protection for our young people. Because the school does not cover all expenses, the best available insurance for the amount of money is a combination of our own school insurance and your own personal family insurance. Our school insurance covers a wide range of accidents in all sports.

In order for our athletes to be insured as well as possible, we require each participant to purchase the above mentioned school insurance, or else to provide us with a waiver form which explains that the athlete is adequately insured with your own personal family insurance. In no case will North Hills School District be responsible for the cost of prescriptions, special medications, and the like.

This is to acknowledge that my child is adequately covered by our own personal insurance against injuries sustained in interscholastic athletes. I understand that I have the option of purchasing insurance through the North Hills School District.

Signature of Parent/Guardian_________________________________Date:___________

Notice of Privacy Practices

I hereby authorize the release of information, including but not limited to the results of the physical examination, to school personnel, coaches, athletic trainers, and team physicians. The information being released is to assist the above-mentioned in the evaluation of the physical well being of the athlete. Signature of Parent/Guardian:________________________Date:_____________

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Warning and Notification of Risk

Playing, practicing, or participating in any sport can be a dangerous activity involving risks of injury. The dangers and risks include, but are not limited to; death, serious neck and spinal injuries, which may result in complete or partial paralysis, brain damage, serious injury to virtually all internal organs, serious injury to virtually all bones, joints, ligament, muscles, tendons and other aspects of the muscular system, and serious injury or impairment to other areas of the body, general health and well being. Playing, practicing or participating in interscholastic activities may result not only in serious injury, but in a serious impairment of future abilities to earn a living, to engage in other business, social and recreational activities and generally to enjoy life.

I have read the above WARNING. I am aware and understand the risks of playing, practicing and participating in interscholastic activities. I recognize the importance of following the coaches’ instruction regarding the activity.

Signature of Student:__________________________________Sport:_______________

We are the parents/legal guardians of the above named student. We have read the Warning and Notification of Risk and understand the risks of our child participating in interscholastic activities.

Signature of Parent/Guardian______________________________Date:____________

QUESTIONS SHOULD BE ADDRESSED TO NORTH HILLS ATHLETIC DEPARTMENT

412-318-1437

Page last edited on: 2008-01-11
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