Insurance Waiver and Release Form

Dear Parent:

Your child has indicated an interest in participating in the Butler Area School District Athletic Program by trying out/participating in one of the Butler Area School District Interscholastic Sports Programs. We know that it is your will as well as ours that every possible precaution be taken to protect our students from injury. We do our utmost to promote this by proper training, by the use of good protective equipment, by supervising all activities, and by encouraging good safety habits.

Despite all our efforts, accidents do happen occasionally in athletics as elsewhere. The school is not legally liable for medical and/or hospital expenses, damages related to pain and suffering, loss of earning capacity, or any other expenses or damages resulting from athletic injuries incurred in interscholastic sports.

Although the Butler Area School District does not provide school insurance (*except for football grades 9-12, please contact athletic trainer for forms and restrictions), school insurance may be purchased through the school district. Applications are available at all of the principal’s offices in the district as well as the Athletic Office. Since the school insurance does not cover all expenses, the best available insurance for the amount of money involved is a combination of the school insurance and your own personal family insurance.

We, the undersigned parent or guardian, intending to be legally bound, do hereby release, discharge, and waive the Butler Area School District from any liability for any injury to our child resulting from any cause whatsoever in connection with our child participating in one of Butler Area School District Interscholastic Sports Programs. We further hereby agree to indemnify and hold harmless the Butler Area School District from any expenses that we may incur in connection with the participation of our child in one of Butler Area School District Interscholastic Sports Programs.

Warning and Notification of Risk

Playing, practicing, or participating in a sport can be a dangerous activity involving risk of injury. There is no limitation to the nature or severity of the possible injuries in some sports. Some sport injuries can result in serious permanent impairment or be life threatening. Unfortunately, injury may occur simply due to the nature of the sport without the occurrence of any unusual event and without fault.

I have read the above WARNING. I am aware and understand the risks of practicing, participating in, and playing interscholastic activities. I recognize the importance of following the coaches’ instructions regarding the activity.

*SIGNATURE OF “STUDENT “____________________________________________ Date:____________

YOU MUST CHECK “JUST ONE” OF THE LINES BELOW

______ This is to acknowledge that my child has my permission to participate in one of Butler Area School District

Interscholastic Sports Programs and is adequately covered by our own personal insurance policy.

______ This is to acknowledge that my child does not have personal insurance or adequate personal insurance against

injuries sustained while participating in one of Butler Area School District Interscholastic Sports Programs. The Butler Area School District REQUIRES all athletes to have medical insurance. Therefore, I am aware medical insurance must be purchased before the athlete is permitted to try out, practice, or play any sport. Please contact the Athletic Office as soon as possible for more information and requirements if you checked this line.

I/We are the parents/legal guardians of the above named student. We have read the Insurance Waiver and Release, the Warning and Notification of Risk, understand the risks of our child participating in interscholastic activities as well as understand that the Butler Area School District REQUIRES each student athlete carry medical insurance.

If your insurance information should change after the original completion of this form as well as Section I of the CIPPE form, you must contact the Athletic Office IMMEDIAETLY with the updated insurance information.

*Signature of PARENT/GUARDIAN ____________________________________ Date:_____________