The Messalonskee School District does not carry insurance coverage for the summer clinics.  Please list your insurance company and policy number in case of an emergency.

Insurance Company_____________________________

Policy # _____________________________________

I do hereby assume responsibility for my child for the risks involved in participating in the “Summer Youth Sports Clinics”.  I understand that, in case of personal injury while participating in the Clinic, I will not hold Messalonskee Skills Clinic, any staff member, or coach

of the clinic responsible.  I also accept that my insurance company or I will pay any medical care expense or property loss.  Finally, I give my permission, in case of emergency, to allow the staff and coaches of the Skills Clinics to seek medical help for my child.

Parent’s Signature ______________________________

Date _________________________________________

please sign and date