School Board of Pinellas County, Florida
Health Science Education
VERIFICATION OF ACCIDENT FINANCIAL RESPONSIBILITY

I, ___________________________________, verify that I am enrolled in the _________________________
	(student’s name)								(program)
through _________________________________(name of school), and should the need arise for medical care due to an accident and/or injury while participating in my regularly scheduled theory or clinical learning activity, my medical expenses will be:  (check, sign and date appropriate section below)

_____  1.  covered by my personal or family health and accident insurance policy
		Insurance Co. _____________________________ Policy # ______________________________
		Effective Date ____________________________ Expiration Date ________________________
	    I understand any difference in actual cost and insurance benefits is my personal responsibility.

	    Signature of Student _____________________________________ Date _______________________

	    (If a minor) Parent/Guardian Signature ________________________________ Date ______________

______  2.  paid by me or my family and my/our personal responsibility.  I have no health/accident insurance.

	    Signature of Student _____________________________________ Date _______________________
	   
   (If a minor) Parent/Guardian Signature _______________________________ Date _______________

 _______  3. covered under Workman’s compensation since I am employed by that agency where my clinical                     learning experience is held and I am being paid by that agency while I attend classes.

	Signature of Student ____________________________________ Date ________________________

_______  4.  covered by the student accident insurance policy made available through the Pinellas County Schools (check one)       a. 24-hour coverage ____   b. class time only coverage ____ 
	Policy effective date(s) August _____ through August _____.  I am aware that if I am in the program beyond the policy year I must purchase another policy.  Coverage starts on the date the company received the premium and goes through the end of the current policy year.  I agree to pay the difference between insurance benefits and charge for any required services.  I also understand that if I select the class time only coverage, I must be actually enrolled in a program and in class to be covered.
	Date premium and application mailed _____________________________
	Ending date of program_________________________________________

	Signature of Student ____________________________________ Date _________________________

_______ 5.  covered by Medicaid, Medicare, etc.

	Signature of Student ____________________________________ Date __________________________
I understand that I am not entitled to any benefits or workman’s compensation in the event of any injury occurring on the premises of the class/clinical learning experience unless I am being paid by that agency while I attend classes.
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