INSURANCE INFORMATION
REGISTRATION 2014-2015
STUDENT NAME: Do you have any reason to believe your child is not physically able to take part in all school-sponsored activities he/ she chooses? ☐YES ☐NO If yes, please explain: Is there anything unique related to your child’s physical condition or medical history which the school should know? ☐YES ☐NO If yes, please explain: ANY KNOWN ALLERGIES: PARENT PERMISSION FOR SCHOOL TRIPS: I hereby give permission for my student to take part in field trips and other school-sponsored activities included in the planned program of the school. Transportation may be provided at the discretion of Western Mennonite School in such form as approved. ☐YES ☐ NO I authorize Western Mennonite School, its employees and my child’s weekend/hospitality home (if applicable) to administer first aid or secure the services of a physician or hospital, and to incur expenses for necessary services in the event of accident or illness. I will provide payment for these services. Every reasonable effort will be made to contact the parent(s) as soon as possible. Do you agree to the above statement? ☐YES ☐NO INSURANCE COVERAGE: COMPANY: GROUP #: POLICY #: NAME OF POLICY HOLDER: PARENT/GUARDIAN SIGNATURE My signature indicates that all information provided on this form is correct to the best of my knowledge. Signature:
Relationship:
Date: ____________
Emergency contact number(s): ____________________________________________________________________ _______________________________________________________________________________________________
INSURANCE DISCLAIMER: Although I realize that Western Mennonite School requests that I provide health insurance for my child, I do not have any health insurance coverage at this time. I will be responsible for any medical bills accrued by my child while attending Western Mennonite School and will not hold Western Mennonite School responsible for those bills. PARENT/GUARDIAN SIGNATURE:
DATE: ______________ FORM REQUIRED FOR EVERY STUDENT