Winston-Salem/Forsyth County Schools s4

WINSTON-SALEM/FORSYTH COUNTY SCHOOLS

Sports Participation Insurance Requirement

7th and 8th GRADE only

6th grade do not fill this side out

Dear Parent of Guardian:

In order to play interscholastic sports (compete between schools) a student must be adequately covered by accident or medical and hospitalization insurance. Your child may be adequately covered by an insurance policy which you have purchased or which is provided by your employer. You should check your policy to be certain that it provides full family coverage and does not exclude protection while participating in interscholastic sports.

If your child is not covered by medical and hospital insurance, the school system has made arrangements with the Young Group for you to purchase this insurance. This insurance does not cover all expenses in case of injury. It is to help offset costs to the family in the event that the service is needed. If this protection is desired, the funds must be provided by the parents. This is the normal school-time and/or 24-hour coverage insurance offered to all students at the beginning of each school year. Either plan is acceptable; however, the lower premium insurance pays considerably less if medical attention is needed.

PARENT OR GUARDIAN MUST COMPLETE THE FORM BELOW AND SIGN IN SPACE PROVIDED

Name of Student ______School ______

Name of Parent ______Telephone # ______

____ 1. I have a family accident of medical and hospitalization insurance plan in effect that provides coverage for my child playing interscholastic sports, and I hereby certify that I will maintain this insurance in full force and effect. If this policy is cancelled for any reason, I will notify the school within five days.

Name of Insurance Company ______

Address of Ins. Company ______

Policy No. ______Date of Coverage ______

____ 2. I do not have coverage under a family medical plan, and I wish to purchase one of the student accident insurance plans made available through the school system.

______

Signature of Parent or Guardian Date

Student Name ______Date______Grade Level __6 7 8_(circle one)_

Flat Rock Middle School

Intramural / Parent Permission Form

The written permission of a student's parent/guardian is required for participation in intramurals, after school activities, and athletic team tryouts. In addition, the school system requires that the parents assume financial responsibility for all medical and hospital bills incurred as a result of an accidental injury their child sustains while involved in the program. Intramurals and athletics do involve some risk of physical injury to the child. Parents should be aware of these risks before granting a child permission to participate.

I, ______( Parent/Guardian Name ), grant my child permission to participate in intramurals and athletic tryouts at Flat Rock Middle School.

I certify that my child has no known medical or physical condition that might make participation in intramurals and athletics detrimental or hazardous to his/her health with the possible exception of: ______

If my child suffers an accidental injury while participating in intramurals or athletics, I agree to pay all of the medical and hospital bills.

I also grant permission for school officials to obtain necessary medical treatment for my child in an emergency when I cannot be contacted. I understand that reasonable efforts will be made to contact me prior to treatment.

______(Parent Signature)

Address: Contact Information: ______(Home phone)

______(Cell phone)

______(Work phone)

Emergency Contact Name______

(Phone) ______