Lakeview School District
“Home of the Sailors”
2482 Mercer Street
Stoneboro, PA 16153-2799
Phone: 724-376-7911
TO:
Fax: 724-376-7910
Parent/Guardian of Extra-Curricular Players, i.e. Junior High Wrestler, Junior
High Boys’ Basketball, Junior High Cheerleader, Varsity Wrestler, Varsity Boys’
Basketball, Varsity Girls’ Basketball, & Varsity Cheerleader
FROM: Business Office
RE:
Medical Insurance – 2015-16 Winter Sports Program
DATE: June 22, 2015
In order for your child to participate in Extra-Curricular Sports (Grades 7-12), the following
form must be completed and returned to the Business Office by Wednesday November 11,
2015. An athlete will not participate until both forms (yellow, white) are completed and
returned. Athletes turning in forms late will be assessed a one day “no practice” penalty
for each day the form is late.
Student Name
Date of Birth
Address
Home phone
PARTICIPATING SPORT:
E-mail
2015-16 Grade
JrH Wrestling
JrH Boys’ Basketball
JrH Cheerleading
Varsity Wrestling Cheer
Varsity
Varsity
Varsity
Varsity
Wrestling
Boys’ Basketball
Girls’ Basketball
Basketball Cheer
Complete the following and sign below.
The above named student is covered under our medical insurance policy. A
COPY OF PARENT/GUARDIAN’S INSURANCE CARD MUST BE ATTACHED TO THIS
FORM AS PROOF OF INSURANCE. (Copies can be made in the Building Offices.)
Name of Insurance Company -
Policy Number -
*ANY CHANGE IN MEDICAL COVERAGE MUST BE REPORTED TO THE BUSINESS OFFICE AS SOON AS IT OCCURS.*
The above named student is not presently covered under any medical insurance
policy. An individual policy will be purchased prior to November 11, 2015 (date all forms
are due). Proof of purchase must be provided to the Business Office.
Insurance is available for purchase through the Business Office (for student 24-hour
coverage). The completed insurance form along with payment must be returned to the
Business Office.
NOTE: STUDENTS WHO DO NOT HAVE MEDICAL INSURANCE WILL NOT BE PERMITTED TO PRACTICE OR PLAY
EXTRA-CURRICULAR SPORTS.
PARENT/GUARDIAN WILL BE RESPONSIBLE FOR ALL EXTRA-CURRICULAR
RELATED MEDICAL EXPENSES. IF THERE ARE ANY QUESTIONS, PLEASE CALL THE BUSINESS OFFICE.
Signature (Parent/Guardian)
Date