Insurance Release Form

Student Accident Insurance is available for all students at a minimal fee. Students participating in the athletic programs must have either school insurance or waive the school insurance because they have adequate coverage through their parent's policy.
To waive the school insurance, the following must be signed and returned to the Athletic Director before participating in any sport.
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We would like to waive the school insurance for our son/daughter

__________________________________ / _________________
Name / Grade

who will be participating in athletics in the Willard City Schools.
We understand that by waiving the school insurance we and/or our
insurance coverage will bear all cost of any injury and neither the
school nor the school insurance company will be responsible for any
cost of any injury.

_________________________________
Parent's Signature
_________________________________
Date

Date Received _____________________ Received by __________________
(For School Use Only)