Parent Statement & Insurance Verification

All required questions are notated with an asterisk (*).


** To view a PDF in your browser, install/enable a PDF Reader extension/plugin.

Participation in athletics is voluntary. It is important to realize that there is a possibility that catastrophic injury may occur due to athletic competition. The Cumberland County School District has an insurance policy (non-duplicating), which covers injuries sustained while involved in school athletics. This policy will pay only for medical expenses not covered by your own health insurance coverage. A sample of the policy BENEFIT PACKAGE AND LIMITATIONS is available through the Cumberland County School District Athletic Department.

This is to certify that I have read the statements on this card and hereby give permission for my child to participate in the sport named.


Signatures


Student Athlete


Print Name:

Signature:

Date:

Parent / Guardian


Print Name:

Signature:

Date:

My signature indicates that to the best of my knowledge, my answers and information provided to the above questions are complete and correct. I understand that the information that I have provided on this form may be used for analytical and research purposes. I consent to the access and use of this data by the Cumberland County Schools, and Arbiter, LLC.