Parental Insurance Waiver

George-Little Rock Community Schools Parent(s) and Guardian(s):

The School District does not provide any type of health or accident insurance for injuries incurred by your child at school. We encourage all families to have accident coverage on their children prior to participation in any sports or school-sponsored activity. Please read the entire policy offering to determine if this program is a needed supplement to your own primary health insurance. If you feel your coverage is adequate, please fill out this form.

Full-Time Coverage (K-12)

24 Hour with No sports

$ 99.00

Full-Time Coverage (7-12)

with all sports except football 9-12

$174.00

School-Time Coverage

(K-12) with no sports

$ 16.00

Football (9-12)

Grades (7 & 8 are covered by the All Sports Coverage)

$250.00

Extended Dental

(PK-12)

$ 9.00

In making application for coverage, please read brochures explaining options carefully.

Coverage will become effective at 12:01 a.m. following the date the enrollment form and premiums are received and dated by the school.

Questions about the plan may be directed to Student Assurance Services, Inc., at (651) 439-7098, or toll free at 1-800-328-2739.

Please fill out and submit the form below if you already have adequate insurance.

We, the undersigned, feel we have adequate insurance protection for our son/daughter while practicing or participating in Interscholastic Sports or other School-Sponsored Activities.

If you would like information about GLR schools or if there is any way we can assist you, please do not hesitate to contact us. We would love to give you more information about any of our schools.

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