Ihavewaivedthe Medical/Healthinsurancecoveragethathasbeenapprovedbythefultoncountyschool

FULTONCOUNTYSCHOOLSYSTEMDEPARTMENTOFATHLETICS VERFICATIONOFINSURANCECOVERAGE

EffectiveforSchoolYear2015-2016

Ihavewaivedthe medical/healthinsurancecoveragethathasbeenapprovedbytheFultonCountySchool

Systemandofferedtomychild, DateofBirth:_(NameofChild)

The medical/healthinsurancethatIamusingfor mychildforthecurrentschoolyearat

isprovidedby and

(SchoolName)(Nameof InsuranceCompany)

theinsurancepolicynumberis . Thisinsurancepolicy

(InsurancePolicyNumber)

isineffectfrom: to . (Date) (Date)

Attacha copyofMedical/HealthInsuranceCertificatetothisformtoverifyinformationlistedabove.Thankyou. Theabovemedical/healthinsurancecoverageprovidesforthefollowinginterscholasticathleticsactivities:

1.

2.

3.

4.

We/IunderstandthatperTheGeorgiaHighSchoolAssociationaPre-participation Physicalevaluationmustbeperformedbya physiciantomedicallyscreeneachstudentwhoparticipatesintheinterscholastic athleticprogramsoftheFultonCountySchool District.We/Iunderstandthatabasicmedicalscreening(therequiredphysicalexam)isgeneralinnature andlimitedinscopeand doesnotindicateorassure me/usthatmy/ourchildiscompletelyfreefromimpairments.If I/wewish foramoredetailedphysical examtobeperformeduponmy/ourchildthenitismy/ourresponsibility toarrangeandtopayforsuchanexam.Ifthismore detailedexamisperformed,itismy/ourresponsibilitytonotifytheFultonCountySchoolDistrict,andit’sappropriateemployees, ofanypotentialmedicalproblemsuncoveredbyanyphysicalexam giventomy/ourchildother thanthegeneralphysicalrequired bytheschool system forathleticparticipation.Iagreetofully waive anyandallclaimsofwhatever nature,fully andfinally,now andforever,formy/ourchild,formyself,myestate,myheirs,myadministrators, myexecutors,myassignees,myagents,my successors,andforallmembersofmyfamily,andtoindemnify,release,defend,exonerate,dischargeandholdharmlessall current,formerandfuturemembersoftheSchoolBoardoftheFultonCounty BoardofEducation,allcurrent,formerandfuture employeesoftheFultonCountyBoardofEducation,theirschools,theirtrustees,officers,BoardofEducation,agents,coaches, athletictrainers,physicians, volunteers,andanyotherpractitioner ofthehealingarts(an“Indemnified Party”)fromany andall liability, personal orpropertydamages, claims,causesofaction ordemands broughtagainsttheFultonCounty SchoolDistrictor indemnifiedpartyarisingoutofanyinjuriestomy/our childortohisorherpropertyorlosses ofanykindwhichmayresultfrom orinconnectionwith hisorherparticipationinanyactivity relatedtotheinterscholasticathleticprogramsprovidedbytheFulton CountySchoolDistrict.

Mysignaturebelow atteststhatIhaveread,understoodandconcurwiththeinformation onthisform,andthatIgiveconsentfor mychildtoparticipateintheathleticprogramsasstatedabove.

ALLPARENTS/GUARDIANS/MUSTSIGNBELOWANDDATE

Signatureofparent/guardian: Date:

Signatureofparent/guardian:Date:

Signatureofstudent:Date:

PRIOR TOPARTICIPATION INANY CONDITIONING,TRYOUT,PRACTICE SESSION,OR PLAYIN ANY INTERSCHOLASTICATHLETICACTIVITY,THESTUDENT-ATHLETEMUSTSUBMITTHISFORMFORPARTICIPATION ININTERSCHOLASTICATHLETICSTOTHE COACH OFTHEACTIVITY. FAILURETOSUBMITTHISFORM WILL DELAY THE ELIGIBILITY OFTHE STUDENT-ATHLETE TO JOIN THE TEAM

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