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.