MIME-Version: 1.0 Content-Location: file:///C:/EC779E14/HEALTHSTATEMENT.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" STUDENT’S NAME: __________________________

STUDENT’S NAME: __________________________

        =             &nb= sp;                     =             &nb= sp;            =             &nb= sp;            =       

 

  = ;   Child #1: ________________________________________________<= /p>

 

  = ;   Child #2: ________________________________________________<= /p>

 

  = ;   Child #3: ________________________________________________<= /p>

 

  = ;   Child #4: ________________________________________________<= /p>

 

PLEASE NOTE:         = THIS INSURANCE WILL NOT COVER FOOTBALL= !

 

HEALTH INSURANCE STATEMENT

 

I understand that Grace Academy cannot be responsible for the health insurance for all students attending the school.  The school is respons= ible to provide a safe and supervised environment and the parent is to provide insurance to cover physical difficulties incurred on campus.

 

________________________________________ Parent/Guardian signature

 

________________________________________ Pl= ease PRINT name

 

 

Grace Academy 2004/2005

Health Insurance Agreement

 

 

We would like to sign up for the policy available through the school.  The policy is with Standard Life.<= span style=3D'mso-spacerun:yes'>  The cost is a one time fee of $42 = for 24 hour coverage or $6.25 for school time coverage.

 

Please check desired coverage:    24 hour___________

        &= nbsp;           &nbs= p;             = School time only _______

 

Please check desired payment:     school bill ________

        &= nbsp;           &nbs= p;             = Payment included _____

 

 

 

 

  = ;            &n= bsp;            = ;            &n= bsp;  

THIS FORM MUST BE RETURNED TO THE ELEMENTAR= Y OR HIGH SCHOOL OFFICE BY AUGUST 30TH.          &= nbsp;