INSURANCE REJECTION FORM This is to certify that I have been
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Student Name:________________________________I.D.#_______________Grade:_______ INSURANCE REJECTION FORM This is to certify that I have been given the opportunity to participate in the student accident insurance plan provided by the Harlingen CISD, and that I decline to participate. I understand that the District is not responsible for any medical expenses or other costs of treating injuries. I will accept responsibility for any medical expenses incurred while my child is at school or is on any schoolsponsored trip or activity. Parent Signature Date FORMA DE RECHAZANDO DE SEGURO Con esta forma doy saber que yo tuve la oportunidad de participar en el plan de seguro accidental de estudiante proporcionado por el Harlingen CISD, y que yo rechaze a participar. Entiendo que el Districto no es responsable de ningún gasto médico ni otros costos de tratar las heridas. Aceptaré responsabilidad de cualquier gasto medico contraído mientras mi nińo/a esta en la escuela o esta en algun viaje o actividad escuela-patrocinados. Firma de Padre Fecha
