is covered by medical insurance under my own policy which is with
(Insurance Company) (Policy Number)
Please check one of the following options:
I waive the school insurance in lieu of my own policy. This insurance will cover my son/daughter while participating in athletics for the school year .
I currently do not have a health insurance policy and will purchase “KID GUARD” or a similar policy (Name of policy) to cover my son/daughter.
(Verification of purchase must be presented to the office.)
(Signature of Parent/Guardian) (Date)
Health Insurance Policy is required for participation in extracurricular athletic activities.
(RETURN COMPLETED FORM TO CHS OR CMS OFFICE)