Morgantown Middle School Lacrosse

Athletic Insurance Verification Form

      The undersigned, as parent or guardian of the child named below, desires that the
 child participate in the Middle School Lacrosse program. I also understand that the
 Monongalia County Board of Education and/or coaches do not carry medical

or accidental insurance for students, and I hereby certify that my child is covered by a

personal insurance policy, which I have in force. If your insurance changes, a

new form must be completed.
        In consideration of the coaches efforts on my child's behalf, I do hereby
 voluntarily assume all risk of accident, injury, damage and/or loss to my child or my
 child's property which, may arise out of my child's participation in the athletic
 program, and hereby release and discharge Monongalia County Board of Education
 and all personnel associated or connected with the athletic program for every claim,

liability, or damage of any kind.
        My execution of this release also authorizes routine medical care for my child and
 treatment not considered routine to be referred to a local physician or medical facility at
 my expense.


Date ___________________ 

Participant's Name______________________________________________________

Grade__________ School _________________________________________________

Parent/Guardian's Name__________________________________________________

Home Address __________________________________________________________

Home Phone ______________ Work Phone _______________ Cell _______________

Insurance Company _______________________________ Policy # _______________

Policy Holder's Name ____________________________________________________

Effective Date ____________________ through ______________________________

Last Physical: Date ____________________ Doctor ___________________________

Parent/Guardian Signature _______________________________________________