Pajaro Valley Unified School District
Permission for Participation in Extracurricular Activities/Proof of Insurance
My child, , has my permission to participate, as appropriate, in the CIF sponsored athletic program at Aptos High School. Transportation to activities away from the campus MAY NOT always be furnished by the District.
Athletic Insurance Information Statement
This is to inform you that the school district does not carry medical or dental insurance for students injured on school premises, while under school jurisdiction or when involved in other school district activities. State law requires that any student wishing to participate in interscholastic athletics must have adequate medical insurance prior to being allowed to participate.
The California Education Code Section 32221 requires public schools to make available for each member of an athletic team insurance protection for medical and hospital expenses resulting from accidental bodily injuries in one of the following amounts:
a. A groups or individual medical plan with accidental benefits of at least two hundred dollars ($200) for each occurrence and major medical coverage of at least ten thousand dollars ($10,000), with no more than one hundred dollars ($100) deductible and no less than eighty percent (80%) payable for each occurrence.
b. Group or individual medical plans which are certified by the Insurance Commissioner to be equivalent to the required coverage of at least one thousand five hundred dollars ($1,500).
c. At least one thousand five hundred dollars ($1,500) for all such medical and hospital expenses.
The insurance otherwise required by this section shall not be required for any individual team member or student who has such insurance or a reasonable equivalent of health benefits coverage provided for him/her in any other way or manner, including, but not limited to, purchase by himself/herself, or by his/her parent or guardian.
I have sent a check for accident insurance as indicated below in order to meet the requirements of the California law (check the appropriate response(s).
£ Tackle Football Insurance (covers tackle football only)
£ School Time Insurance (covers sports other than football)
£ Full Time Insurance (covers sports other than football)
OR £ I have health or accident insurance for my daughter/son/ward which meets the requirements of California law and elect not to
purchase student insurance (list company, policy or group number).
Company Name Policy Group Number
I will promptly notify the school in the event insurance coverage no longer applies to my son/daughter/ward.
Warning to student & Parents
Serious, catastrophic and perhaps fatal injury may result from athletic participation.
By its very nature, competitive athletics may put students in situations in which serious, catastrophic, and perhaps, FATAL accidents may occur.
Many forms of athletic competition result in violent physical contact among players, the use of equipment which may result in accidents, strenuous physical exertion and numerous other exposures to risk of injury.
Student and parents must assess the risks involved in such participation and make their choice to participate in spite of those risks. No amount of instruction, precaution, or supervision, will totally eliminate all risk of injury. Just as driving an automobile involves choice of risk, athletic participation by high school students also may be inherently dangerous. The obligation of parents and students in making this choice to participate cannot be overstated. There have been accidents resulting in death, paraplegia, quadriplegia and other very serious permanent physical impairments as a result of athletic competition.
By granting permission for your student to participate in athletic competition, you, the parent or guardian, acknowledge that such risks exist.
By choosing to participate, you, the student, acknowledge that such risks exist.
Students will be instructed in proper techniques to be used in athletic competition and in the proper utilization of all equipment worn or used in practice and competition. Students MUST adhere to that instruction and utilization and MUST refrain from improper uses and techniques.
As previously stated, no amount of instruction, precaution and supervision will totally eliminate risk of serious, catastrophic, or even fatal injury.
If any of the foregoing is not completely understood, please contact your school principal for further information.
This form must be on file at the school.
This will acknowledge that we have read and understand the material contained in the notice to athletes and parents or guardians.
Parent or Guardian Signature Date
Student Signature Date
Revised 2/19/09