CONFIRMATION OF PERSONAL HEALTH INSURANCE

I, _______________________________, hereby declare that I possess medical insurance administered by _______________________________________ Insurance Company.

Policy # ____________________________ which will provide coverage for medical and hospital expenses resulting from accidental bodily injury while practicing for, or participating in, any training event attached to Team Kelly White’s Triathlon Club.

_____________________________________________     _____________                

             (signature of Tri Club participant)                                     (date)