Parent Permission-Ins.

LAST                  FIRST                   MIDDLE         BIRTH DATE     GENDER     SCHOOL YR      ASB              

MOSES LAKE SCHOOL  - ATHLETIC ELIGIBILITY
PARENT’S PERMISSION

Please circle the sports the student is interested in: Football-Volleyball-Cross Country- Soccer-Basketball-
Swim-Wrestling-Golf-Softball-Baseball-Tennis-Track-Drill Team-Cheerleading-Girls Bowling

I hereby give my consent that ___________________________may participate in one of the above sports in the Moses Lake Schools and certify that the above information is correct.

My child has a disability resulting from an accident or serious illness which school officials should know about as follows: ______________________________.  If no disability, state NONE.

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PARENT FULL SIGNATURE

INSURANCE INFORMATION

He/She will be covered with athletic injury insurance by:  FAMILY INSURANCE                        ___________           
If SCHOOL INSURANCE, company providing the coverage is:        ___________               POLICY # ______________________
It is recommended that the student be covered by the School Accident Coverage or one with the following minimum   provisions:
(1)  Minimum death benefit of $2,500; (2)  A maximum payment of any one  injury of at least in aggregate of $15,000 per accident; (3) Coverage equivalent to the Washington State Industrial Insurance Fee Schedule for doctors’ services or hospitalization with a 30-day minimum for the latter; (4) X-Rays to a minimum of $50.; (5) Dental coverage equivalent to the Washington State Industrial Insurance Fee Schedule to at least $100 per injury; (6) Waiting period provisions following an injury be deleted from approved policies with understanding that written approval of doctor be sufficient evidence to permit student to return to practice or play; (7) All approved policies shall provide that a 90-day limit for completing claims shall be counted from termination of medical service and discharge of patient rather than from date of injury.

I have insurance coverage, which covers Interscholastic Athletics, the equivalent or better than the recommended insurance coverage of the Washington Interscholastic Activities Association, will continue to keep it in force throughout the sports season, and therefore I do NOT wish to enroll ____________in the School Accident Coverage Plan. I accept full responsibility for the cost of treatment for any injury which he or she may suffer while taking part in the program. Please waive this requirement and permit him/her to take part in athletics and sports days.  The Principal is authorized to contact the Company named above to verify coverage limitations.

I accept full responsibility for the cost of treatment for any injury which he/she may suffer while taking part in the program.  Please permit him/her to take part in athletics and sports days.

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PARENT/GUARDIAN FULL SIGNATURE