Wickford Middle School
Intramural Participation Permission Form
Intramural activities are offered after school at various times
throughout the school year. Mondays and Wednesdays require parent
pick up by 3:30 p.m. or the student to be a walker. If a student is
unable to have transportation home by 3:30, they should participate
on Tuesday/Thursday. On Tuesday and Thursdays the late bus is
available. The late bus arrives between 3:45-4 p.m. If you are
picking up your child on Tuesday/Thursday he / she must be picked up
by 3:45 p.m. or they will be sent on the late bus for a safe return
home.
A student may participate anytime during the current school year
provided he/she is academically eligible. All participants are
expected to follow school rules. ALL STUDENTS MUST HAVE HEALTH
INSURANCE TO PARTICIPATE. THIS MAY BE SCHOOL INSURANCE (available for
a nominal fee through the office) OR HEALTH INSURANCE OF EQUIVALENT
COVERAGE (see clarification statement.)
PLEASE COMPLETE ALL SECTIONS AND SIGN BELOW
Student Name
______________________________________________________________________
Address:
_____________________________________________________________________
Phone: _____________________ D.O.B ____________________ Grade:
___________________
Medical Problems:
_____________________________________________________________________
Emergency Contact if parent/guardian is not home:
_____________________________________________________________________
Health Insurance Coverage:
_____________________________________________________________________
|
(company name)
|
(policy no. & effective dates
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School Insurance? yes__________ no _________
I give permission for my son / daughter to participate in the
Wickford Middle School Intramural Program I hereby certify that he /
she complies with the school department insurance policy.
Parent /Guardian Signature:
_______________________________________ Date: ________________
Please note that arrangements should be made in the event of
intramural cancellation. Students need to have a way to contact their
parent / guardian if necessary (prepaid phone cards work well) and be
able to enter their home or stay with a neighbor. Please discuss this
with your child prior to their participation.
Equivalent Coverage Clarification
Policy to be equivalent must contain all the benefits provided by
the School Insurance Policy being offered. An equivalent policy
should contain all of the following:
- For medical expenses resulting directly and independently of
all other causes from accidental bodily injury as stated in the
plan. Medical expenses up to $10,000 for injuries covered
- Medical treatment by a legally qualified physician, surgeon or
osteopath including surgery and x-ray
- Hospital charges including room and board, operating room,
laboratory and anesthetist's fee.
- Prescribed medication and dressings.
- Graduate nurses' fees
- Local ambulance service
- Dentists bills up to $250 per tooth to cover injuries to sound
natural teeth for expenses incurred within twelve months after the
date of the accident.
- Capital sum benefits. If the injuries cause death or
dismemberment within 120 days after the accident, the plan pays in
addition to any other benefits as follows:
- Life: $1,500
- Double dismemberment $10,000
- One hand or one foot $2,500
- Sight of one eye $1,000
- Others; as per policy schedule
- Coverage of and while attending school, school sponsored and
/or supervised activities, and traveling to and from school and
school trips
- Blue Cross-Physicians Service does not cover all the above. A
Life Insurance plan does not. Some health and accident policies do
and most military plans also provide a complete coverage. One
should read the coverage carefully to determine the
equivalency.
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