Athletic Insurance Report

My son/daughter __________________________________has adequate health coverage with:

Name of Insurance Company ______________________________________________

Insurance Co. Policy Number ______________________________________________

Dates covered ___________________________________________ . ____________ _

INSURANCE: Student accident insurance is provided to all students at no cost. This policy insures the student to and from school, during school, and while participating in school-sponsored programs. A separate brochure explaining this coverage was included in each student's orientation package. Students participating in competitive sports, including football, will be covered.

A twenty-four hour policy is available to students-information may be obtained through the school office.

ALL ATHLETES AND CHEERLEADERS MUST PAY A $5.00 FEE {per year) to cover THEIR PARTICIPATION in CATASTROPHIC INSURANCE COVERAGE. This particular coverage has been mandated by The High School League, and DOES NOT SERVE IN PLACE OF MEDICAL COVERAGE. The catastrophic coverage begins at $10,000 and continues to $5,000,000.

I accept full responsibility for any emergency medical service which may be deemed necessary by the coaching staff arising from his/her participation in athletics.

___________________ _____________________________

date

Signature Parent/Guardian

Please list any allergies to medicine that your son/daughter might have or any medication he/she might be taking:

Parent Phone Numbers Emergency Contacts/Phone Numbers

______________________________ _______________________________

______________________________ _______________________________

______________________________ _______________________________

BISHOP ENGLAND HIGH SCHOOL 363 SEVEN FARMS DRIVE CHARLESTON,SC 29492-7534

Athletic Department Telephone {843}849-9599 Ext. 53