University of West Georgia

School of Nursing

 

Health Insurance Waiver

 

 

Student name: ______________________________________________________________

(Print name)

 

 

Health insurance evidence of personal health insurance coverage is optional.

 

Should an injury or illness occur to a nursing student during a scheduled clinical or class activity, the student is responsible for all expenses incurred for medical care or treatment of the injury or illness. All students who have paid their student activity fees are eligible to be seen and treated in the University Health Center. If an injury should occur in a clinical facility during a clinical activity, the student can be seen in the nearest emergency room. The student is responsible for any expenses incurred for treatment received in a clinical facility.

 

Your signature on this document indicates that you understand the above statement.

 

 

Signatures:

 

 

Student:___________________________________ Date: _________________________

 

 

Witness: __________________________________ Date: _________________________