Nhs titans fencing club insurance form

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					                 NHS Titans Fencing Club Permission & Insurance Verification Form

I, _________________________________ give _____________________________
   Parent/Guardian Name (print)                                     Fencer’s Full Name (print)

my permission to join the Northview High School Titans Fencing Club for the 2012/13 season.

I understand that all student athletes MUST have Medical/Health insurance in order to
participate in Fulton County school athletic and extra-curricular activities. Students MUST
be enrolled in medical/health coverage approved by the Fulton County School System or must
be covered through a bona fide private insurance provider.

Please verify insurance coverage below:

I verify _____________________________                (DOB) _________________________
          Student’s Name (print)                                    Month-Day-Year

is covered by medical/health insurance through the following:

INSURANCE PROVIDER: ______________________________________________
                                               (Name of Insurance Provider)

This coverage extends from ____________________ to ________________________
                                      (Date-Month/Day/Year)              (Date-Month/Day/Year)

        1. I understand that although serious injuries are not common, fencing is an athletic
           activity and carries risk of serious bodily injury including the possibility of paralysis
           or even death.
        2. I certify that, to the best of my knowledge, this student does NOT have any medical
           conditions, nor have I been given medical advice, which would prevent him/her from
           participating the sport of fencing.
        3. I certify that the above information is accurate. I will notify NHS Fencing promptly
           if there are any changes to this information. I understand that any false information
           could lead to my son or daughter’s ineligibility to participate in NHS Fencing.
        4. I understand that the student has the responsibility to reduce risk of injury by obeying
           all safety rules, wearing proper protective clothing and maintaining equipment in safe
           working order.

                                   Parents/Guardians must sign below and date.

Signature of
Parent/Guardian _______________________________________________ Date _____________

Signature of
Parent/Guardian _______________________________________________ Date ______________

                Please return signed original to club. You may wish to keep a copy for your records.

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