Linnville Lighthouse After School Program

Athletic Insurance Information

2009-2010 School Year

          It is the policy of the Linnville Lighthouse After School Program, that parents are responsible for any insurance coverage for a child that is involved in any sports activity at the Center. Serious Injuries may occur to those children who participate in sports activities. These injuries include but are not limited to: injuries to bones, ligaments, joints, tendons, damage to internal organs, paralysis due to neck injury and back injuries, brain damage and general deterioration of health and death.

          In an effort to make sports activities as safe as possible for your child, the staff will instruct children concerning the rules and skills of their sport, correct mechanics, and team policies to decrease the possibility of serious injury.

          The parents or legal guardians of any child must sign this form to allow your child to participate in sports programs at our Center.

Students Name: ________________________________

Parents Name: __________________________________

Please check one:

______ My child has injury insurance

______ My child does not have injury insurance

I have read the above information concerning the inherent risk of sports involvement and assume all risks and responsibilities associated with participating in sports activities for my child.

Parent Guardian Signature: ___________________________________

Date: _____________