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Lowpoint-Washburn
Community Unit
School
District No. 21
508
East Walnut
Washburn,
Illinois 61570 (309)248-7522
21st
Century Community Learning Center
After
School Program
INSURANCE
STATEMENT
In order for any student to participate in the
After School Program, they must have a recent physical on file and proof
of insurance. Proof of
insurance may be taken care of by completing and returning the form at the
bottom of this page or by purchasing school time insurance coverage.
Information about the school time insurance may be obtained in the
Unit Office.
Failure
of a student to submit a recent physical and proof of insurance will
result in the student not being able to participate in the program.
INSURANCE
STATEMENT
I
have sufficient accident and hospitalization insurance to cover my child
who will be enrolled in the after school program.
The insurance which covers my child,
_________________________________
is with ________________________________.
(Student
Name)
(Company Name)
________________________________________________________________________
(Parent/Guardian
Signature)
(Date)
Any
questions on this matter should be referred to the program coordinator by
calling 248-7522. Thank you
for your cooperation.
Partners in
Academic Excellence
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