(Players cannot participate unless they have medical insurance).

 

ALL-STAR MEDICAL RELEASE FORM
All players who participate in the All-Star Game(s) must have medical coverage.  In order to be eligible to play you must either
1-Fill in your insurance information below to demonstrate you do have coverage,

Or

2-If you don’t have coverage, then send a check for $10.00 to pay for a one day policy to provide accident insurance and fill in the “One Day Policy” Form.

 

1-Fill in this form if you do have coverage:

Parent Consent and Medical Information
(Players cannot participate unless this section has been completed and signed by the parent or guardian). I understand that the All-Star Game and the host school do not carry medical or accident insurance for the participants, and I here by certify that my child is covered by personal insurance or is included in a policy which I have in place. I authorize routine medical care for my child by the All-Star trainer. I further authorize any treatment considered routine to be referred to a local physician or to an emergency room at my expense. I further authorize and provide my consent and permission for my child to participate in this event.

Players Name __________________________________  School ____________________________

Insurance Company ____________________ Policy _____________ Group # ________

Name of Policy Holder _____________________________ Home Phone __________

Signature of parent/guardian _________________________ Cell phone _____________

send this form to:
Mike Gaffey, Game Director
204 Spruce Ct.
Annville, PA
17003



2-If you do not have coverage, fill in this form and include a check for $10.00 payable to Keckler-Heitefuss Insurance:


                                     "One Day Policy" Form


Name ___________________________________ City   _____________________

Address _________________________________    State ______  Zip  _________

 

Cell phone _____________________    Home phone _____________________

 

Signature of parent/guardian _________________________

Make your check payable to: Keckler-Heitefuss Insurance:
and send everything to: All-Star Coverage, c/o Bill Gaffey
                              417 Bolton Drive, Harrisburg, PA 17112
                                                                                                        

(Players cannot participate unless they have medical insurance).