Consent And Release From Liability Certificate Template

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CONSENT AND RELEASE FROM LIABILITY CERTIFICATE
This completed form must be kept on file by the school.
PART 1.
Student Acknowledgment and Release
(To be signed by student).
I have read the (condensed) FHSAA Eligibility
Rules printed on the reverse side of this “Consent and Release
Certificate” and know of no reason why I am not eligible to represent my school in athletic competition.
If accepted
as a representative, I agree to follow the rules of my school and the FHSAA and to abide by their decisions.
I know
that athletic participation is a privilege.
I know of the risks involved in athletic participation, understand that
serious injury, and even death, is possible in such participation, and choose to accept such risks.
I voluntarily
accept
any
and
all
responsibility
for
my
own
safety
and
welfare
while
participating
in
athletics
with
full
understanding of the risks involved.
Should I be 18 years of age or older, or should I be emancipated from my
parents(s)/ guardian(s), I release and hold harmless my school, The School District of Clay County, Florida (“SDCC”),
The School Board of Clay County, Florida (“SBCC”) and their agents and employees, the schools against which it
competes, the contest officials, and the FHSAA of any and all responsibility and liability for any injury or claim
resulting from such athletic participation and agree to take no legal action against SDCC, SBCC and their agents and
employees, or the FHSAA because of any accident or mishap involving my athletic participation.
I further hereby
authorize the use or disclosure of my individually identifiable health information should treatment for illness or
injury become necessary.
I understand that this authorization is voluntary and that I may revoke it at any time by
submitting the revocation in writing to my school.
Furthermore, I grant the released parties the right to photograph
and/or videotape me and further to use my name, face, likeness, voice, and appearance in connection with exhibitions,
publicity, advertising and promotion materials without reservation or limitation.
The released parties, however, are
under no obligation to exercise said rights herein.
I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE.
Date: __________________
Signature of Student: ___________________________________________________________
Name of Student (printed): ______________________________________________________
PART 2.
Parental/Guardian Consent, Acknowledgment and Release (To be completed and signed by all parents/
guardians.
Where divorced or separated, parent/guardian with legal custody must sign).
A.
I/we hereby give consent for child/ward to participate in the following interscholastic sports
that I/we have not marked out:
Boys’ sports:
Baseball
Basketball
Bowling
Cross Country
11-Man Tackle Football
Golf
Soccer
Swimming & Diving
Tennis
Track and Field
Volleyball
Water Polo
Weightlifting
Wrestling
Other sports added to this form by school: _____________________________________
Girls’ sports:
Basketball
Bowling
Cross Country
Flag Football
Golf
Tennis
Soccer
Fast-Pitch Softball
Swimming & Diving
Track and Field
Volleyball
Water Polo
Weightlifting
Other sports added to this form by school: _____________________________________
B.
I/we understand that participation may necessitate an early dismissal from classes.
C.
I/we consent to the disclosure, by my child’s/ward’s school to the FHSAA, upon its request, of all
detailed (athletic or otherwise) financial, scholastic, and attendance records of such school concerning my child/ward.
I/we further hereby authorize the use or disclosure of my child’s ward’s individually identifiable medical information
should treatment for illness or injury become necessary.
I/we understand that this authorization is voluntary and that
I/we may revoke it at any time by submitting the revocation in writing to my child’s ward’s school.
D.
I/we
know
of
and
acknowledge
that
my/our
child/ward
knows
of
the
risks
involved
in
athletic
participation, understands that serious injury, and even death, is possible in such participation and choose to accept
any and all responsibility for his/her safety and welfare while participating in athletics.
With full understanding of
the risks involved, I/we release and hold harmless my/our child’s/ward’s school, SDCC, SBCC and their agents and
employees, the schools against which it competes, the contest officials and the FHSAA of any and all responsibility and
liability for any injury or claim resulting from such athletic participation and agree to take no legal action against
the SDCC, the SBCC and their agents and employees, or the FHSAA because of an accident or mishap involving the athletic
participation of my child/ward.
I/we further authorize emergency medical treatment for my/our child/ward should the
need arise for such treatment while my child/ward is under the supervision of the school.
Furthermore, I/we grant the
released parties the right to photograph and/or videotape my/our child/ward and further to use said child’s/ward’s
name, face, likeness, voice and appearance in connection with exhibitions, publicity, advertising and promotional
materials without reservation or limitation.
The released parties, however, are under no obligation to exercise said
rights herein.
E.
Please check the appropriate box(es):
____
My/our child/ward is covered under our family health insurance plan which has limits of not less
than $25,000.
Company: _____________________________________
Policy Number: ______________________________
____
My/our child/ward is covered by his/her schools’ activities medical base insurance plan.
____
I/we have purchased supplemental football insurance through my/our child’s/ward’s school.
I/WE HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE.
Date: ____________________
Signature of Parent/Guardian: _________________________________________________
Name of Parent/Guardian (printed): ____________________________________________
Date: ____________________
Signature of Parent/Guardian: _________________________________________________
Name of Parent/Guardian (printed): ____________________________________________

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