Students Application for Participation in Interscholastic Athletics and Verification of Insurance
This form is to be completed by the parent/guardian and student prior to the first practice session. This form is to accompany this athlete to all practices and contests. Parent(s) acknowledge that they have read and understand all the information provided when they sign this form. Failure to submit this form will delay the eligibility of the student athlete to join the team. Participation in supervised interscholastic athletics includes a risk of injury which may range in severity from minor to long term. It is possible to minimize the risk, but not to eliminate it entirely. Participants can and have the responsibility to help reduce the risk of injury. Participants must obey all safety rules, report all physical problems to their coaches and the school's athletic trainer and inspect their equipment daily. By signing this permission form, you acknowledge that you have read and understand this warning. Parents or students who do not wish to accept the risks described in this warning should not sign the permission form.
Athlete's Name *
Your answer
Date *
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Gender *
Address *
Your answer
Phone Number *
Your answer
Alternate Phone Number *
Your answer
Parent/Guardian Names *
Your answer
Grade *
Consent to Participate
I (We) hereby give our consent for our child to represent his/her school in interscholastic athletics. I (We) understand the possible risks involved with participation in interscholastic athletics. If I (we) cannot be reached in the event of a medical emergency, I (we) do give consent for the school to obtain emergency transportation to the physician or hospital of its choice, and such medical care as is reasonably necessary for the welfare of the student if he/she is injured in the course of participation in interscholastic activities
Parent's Signature *
Your answer
Verification of Insurance Coverage
Important: All student athletes are required to have medical/health insurance in order to participate in the Pickens County Schools Interscholastic Athletics Programs. Students must be enrolled in the medical/health insurance coverage that has been approved by the Pickens County School System or enrolled in substitute medical/health insurance through a bona fide insurance provider. Parent/guardian must verify substitute insurance coverage below.
Waiver of School Approved Insurance *
I (We) have waived the medical/health insurance coverage that has been approved by the Pickens County School System and offered to my child
Required
Signature *
Your answer
Proof of Insurance *
The medical/health insurance that I am using for my child for the current school year is provided by (If using School Insurence please type "School Insurance")
Your answer
Policy Number *
Enter the Policy Number Below (For School Insurace enter "0000")
Your answer
Start Date *
The insurace policy is in effect from (For School Insurance enter the August 1, 2017)
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YYYY
End Date *
The insurace policy effective end date (For School Insurance or if you have personal insurace enter May 31, 2018)
MM
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DD
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YYYY
Valid Insurace
I(We) certify that the insurance information provided is valid and current. I(We) acknowledge that it is My(Our) responsibility to notify the PHS Athletic Department of any change in My(Our) child's insurance coverage. Failure on My(Our) part to notify the PHS Athletic Department of any change in coverage or the falsification of insurance coverage will result in My(Our) full responsibility should my child be injured or require medical treatment while participating in PHS Athletics and I(We) hereby release PHS from any responsibility.
Parnet's Signature *
Your answer
Submit
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