Student-Athlete Name _________________________
Sport _________________________
Acknowledgement of Insurance Requirements by Student-Athlete
I, _____________________________________________, attest that I have insurance coverage under an active,
valid insurance policy either under my parent, guardian, legal representative or an individual policy for injuries
that occur during my participation in intercollegiate athletics at Alvin Community College.
If there is a material change in coverage or expiration of coverage, I agree to notify the Alvin Community
College Department of Athletics of this development and update the insurance information I have on file with
the Alvin Community College Department of Athletics.
Student-Athlete Signature__________________________________ Date________________________
Notification of NO Insurance Coverage
I, ________________________________________, attest that I have no insurance coverage in force, and agree
to notify Alvin Community College Department of Athletics if a change occurs to update the insurance
information I have on file with Alvin Community College.
Student-Athlete Signature__________________________________ Date________________________
THIS FORM MUST BE SIGNED AND RETURNED TO THE ALVIN COMMUNITY COLLEGE ATHLETIC OFFICE PRIOR
TO PARTICIPATION IN ANY SPORT.
Return to:
Alvin Community College
Athletic Office, G-133
3110 Mustang Road
Alvin, TX 77511
IN ADDITION YOU MUST INLUDE A COPY (FRONT AND BACK) OF YOUR CURRENT INSURANCE CARD. YOU
MUST ALSO FILL OUT AND TURN IN A NEW ATHLETIC INSURANCE INFORMATION FORM WHICH SHOULD BE
TYPED.
