WAIVER AND INSURANCE DECLARATION
FALL, WINTER, SPRING SPORT PROGRAM AT LAKE ZURICH HIGH SCHOOL
We/I, the parent(s)/guardian(s) of:
_____________________________________, a participant in the co-curricular athletic program at Lake Zurich High School, recognizes and acknowledges that there are certain risks of physical injury and we/I agree to assume the full risk of any injuries, including death, damages, or loss which may be sustained as a result of participating in any and all activities connected with or associated with this program.
Please check the statement which applies.
_______ This student has purchased the group medical and hospitalization insurance offered through the school district.
_______ This student’s parent/guardian maintains separate medical and hospitalization insurance which covers the student’s participation in co-curricular athletic activities.
_______ This student’s parent/guardian does not maintain separate medical and hospitalization insurance, but does assume full responsibility for the cost of medical treatment required by the student as a result of accidental injury sustained in school sponsored co-curricular athletic activities.
Has your student been treated by a medical professional for any illness or injury in the last 6 months?
_______ Yes _______ No
If yes, please give date and reason ___________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
Have they been medically cleared to participate in all co-curricular activities?
_______ Yes _______ No
Are there any current restrictions on his or her activities?
_______ Yes _______ No
If yes, please state restrictions ______________________________________________________________________________________________________________________________________________________
If a student is not medically cleared to participate and/or there are current activity restrictions, medical documentation must be attached.
We/I agree to waive and relinquish all claims we/I may have as a result of our son/daughter‘s participation in this program against Lake Zurich Community Unit District 95 and its officers, agents/servants and employees.
________________________________ _________________________________
Parent/ Guardian Signature Printed Name of parent/guardian
__________________________
Date