Wood River-Hartford Elementary School District #15

Wood River-Hartford Elementary School District #15 Serving Children with Excellence 501 East Lorena Avenue, Wood River, Illinois 62095 618.254.0607 Fax: 618.254.9048 Web Page: www.wrh15.org Patrick Anderson Mark Begando Kelly Bohnenstiehl Heather Johnson Superintendent Principal Principal Principal Wood River-Hartford School District #15 Wood River, Illinois Waiver of Insurance We, undersigned, being the natural parents, guardians of or persons standing in loco parentis of the student named below presently enrolled in Wood River-Hartford School District #15, of Madison County, Illinois, hereby agree to carry health insurance on said student for the purpose of paying health care costs of any injuries or disabilities received as a result of said student participating in cheerleading, athletics, physical education classes, or other extra-curricular activities while a student in said district. Said activities including, but not limited to, basketball, track, wrestling, volleyball, flag football, and weight lifting. The undersigned acknowledge the opportunity to purchase student accident insurance coverage but specifically decline the same and agree to hold said District harmless and indemnify it from any expenses or damages incurred as a result of said student participating in the aforementioned athletics, or other extra-curricular activities. The undersigned hereby acknowledge that the District is not carrying any type of health insurance on said student. The undersigned further agree that in the event our private insurance is canceled or, for any reason, terminated, we will immediately notify the School District and make arrangements to obtain student accident insurance, which is available from a designated insurance company. IT IS UNDERSTOOD AND AGREED THAT NO STUDENT WILL PARTICIPATE IN ATHLETICS OR OTHER EXTRA-CURRICULAR ACTIVITIES SPONSORED BY WOOD RIVER-HARTFORD SCHOOL DISTRICT #15, UNLESS SAID STUDENT IS COVERED BY HEALTH INSURANCE. Student Name________________________________________________________________ Date______________________________________ 20______________ Insurance Company____________________________________________________________ Policy Number________________________________________________________________ TO BE SIGNED IN THE PRESENCE OF WRSD #15 OFFICE PERSONNEL OR A NOTARY PUBLIC Parents/Persons in Loco Parentis Signature_________________________________________ Witnessed by WRSD #15 Personnel or Notary Public_________________________________ Date______________________________________ 20_______________

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Duane Amistadi Chris Edwards Building & Grounds Off Technology Supervisor Coordinator

Carol Elliott Business Manager

Diane Honerkamp Special Education Coordinator

Patty Redman Food Service Director