ENRICH - ENHANCE - PREPARE - SUCCEED
Walton High School Powder Puff
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: ___________________________________________________________
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