I have my own accident insurance coverage for my child.  This is to certify that my dependent has had an adequate medical exam and is physically able to participate in the SERA Rugby Camp.  I give my approval for individuals in charge to have my dependent treated professionally in case of sickness or injury.

Name of Insured _______________________________________________________

Insurer___________________________________     Policy #____________________

Address______________________________________________________________

CIty____________________________    State____________    Zip________________

Please list medical concerns that the staff should be aware of: ____________________

_____________________________________________________________________

_____________________________________________________________________



Please print this page and mail the information, along with the registration and check, to SERA,  Attn:  S. Nigel Platt, PO Box 14790, Greenville SC 29610.