INSURANCE REJECTION FORM This is to certify that I have been

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