DUNLAP MIDDLE SCHOOL INSURANCE WAIVER

Name: _______________________________________________________

Address: _____________________________________________________

Home Phone ________________

Birthdate: __________________

Grade in School: ________

Parent/Guardian Name(s): ____________________________________________

Emergency Phone ___________________________

Please allow _________________________________ the privilege of participating in interscholastic athletics during the 2007-2008 school year. If there are any sports in which I do not want him/her to engage in, I have noted the fact below. I understand that there are risk of serious injury (and possibly death) inherent in participation in middle school sports. I have discussed this possibility with my student athlete and we are both aware of the injury risk involved. I understand that the school district will take every reasonable precaution to avoid the occurrence of accidents and therefore it is not responsible for accidents that occur as part of athletic participation.

I, UNDERSIGNED PARENT/LEGAL GUARDIAN OF __________________________ DO HEREBY CERTIFY THAT HE/SHE IS PRESENTLY COVERED UNDER THE FOLLOWING MEDICAL/HOSPITAL EXPENSE INSURANCE:

Name of Insurance Company_________________________________________

Sports not to be engaged in: __________________________________________

Parent/Guardian Signature: ___________________________________________

Date: ________________

Student Signature: _________________________________________________

Date: ________________