STEVENSVILLE SCHOOL ATHLETICS INFORMED CONSENT AND
INSURANCE VERIFICATION FORM

Extracurricular activities may include physical contact and physical exertion. There is an inherent risk of injury in the activity. By signing this agreement, I acknowledge that the School District staff try to prevent accidents. I agree to accept responsibility for my student’s participation in the school activities. The activity is strictly voluntary.

I, the undersigned, hereby acknowledge and understand that, regardless of all feasible safety measures that may be taken by the School District, participation in this event entails certain inherent risks. I certify that my student is physically fit and medically able to participate or have noted an applicable physical or medical diagnosis at the bottom of this form. I further certify that my student will honor all instructions of district staff and failure to honor instructions may result on dismissal from the activity. I have been informed of these risks, understand them, and feel that the benefits of participation outweigh the risks involved. My signature below gives my child permission to participate in a Stevensville School Activity.

I authorize qualified emergency medical professionals to examine and in the event of injury or serious illness, administer emergency care to my student. I understand every effort will be made to contact the family or contact person noted below to explain the nature of the problem prior to any involved treatment. In the event it becomes necessary for the district staff in charge to obtain emergency care for my student, I understand that neither the district employee in charge of the activity nor the school district assumes financial liability for expenses incurred because of an accident, injury, illness and/or unforeseen circumstances.

The School District DOES NOT provide medical insurance benefits for students who choose to participate in activities programs. Parents or guardians may request information from the school district regarding medical insurance for students. If parents or guardians have their own insurance coverage during the student’s participation, that coverage information is provided below, or parents may notify the School District that they do not have medical insurance.

____ I have personal medical insurance to cover the student’s participation:

INSURANCE (Company Name) ___________________________________________________

Policy # ___________________________________________________________________

 

____ I do not have personal medical insurance to cover the student’s participation and understand that the School District does not provide medical insurance to cover the students. I understand I will be responsible for any medical costs associated with the student’s participation.

Signature Required Regardless of Insurance Coverage:
Student Athlete _________________________________________________________________
(Print) Parent/Guardian ___________________________________________________________
(Signature) Date:________________________________________________________________