ENRICH - ENHANCE - PREPARE - SUCCEED

Walton High School Foundation, Inc.

Please Print the form below by Highlighting  it and hitting print.

Fill it out, sign it and bring it to the front office in an envelope marked Powder puff by November 28th at 12:45 p.m.


  • If you paid on-line, this is the only item you need to turn in. 

  • If you are sending in a check or cash, please include your payment with this form.

  • All Players and Cheerleaders MUST turn in this form!



Walton High School Powder Puff

Insurance Form


                                                     Your Registration will not be accepted unless you have filled out this form and completed your payment.
                                                                                                                                        Please Print Legibly

Name: _______________________________________      Date of Birth: ____________________

Address: ______________________________________     Home Phone: ____________________

 

In compliance with local school policy, which requires students who participate in activities such as Powder Puff to have adequate insurance protection, the following information must be completed.

Company Providing Insurance: ______________________________________________

Name of Insured: _________________________________________________________

Policy Number: ___________________________________________________________


Authorization:

I certify that my child, _________________________________________, is physically fit and in proper physical condition to participate in Walton High School’s Powder Puff activities.


In case of emergency or accident on the school grounds or during this school activity involving my child, ___________________________________, which, in the opinion of school authorities present, requires immediate medical or surgical attention, I hereby grant permission to said school authorities to obtain the services of a physician or to transport said child to the hospital if it is deemed necessary by school authorities.  I hereby grant permission, also, to said physicians to treat said condition unless I am present and request otherwise, or until I later request otherwise.

My son/daughter is adequately and currently covered by accident insurance that will cover injuries sustained while participating in Powder Puff 2018.

To insure medical care, if needed, an ambulance has been reserved for the Powder Puff game.  It is their policy to take an injured student to the nearest hospital, which is Kennestone.

If a choice is possible, please list your hospital preference:________________________________

 

Date: ____________________Signature: ___________________________________________

                                                Printed name: ________________________________________


Relationship to student (circle one):             mother           father              legal guardian