CHARLESTON CUSD #1 ATHLETIC INSURANCE WAIVER

                               

 

 

           

My son/daughter:

                                                (Student’s Name)

 

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)