Consent And Release From Liability Certificate Template (Page 3 of 5) in pdf

The School Board of Clay County, Florida

Off Campus School Activity Parent/Guardian Consent and Release Form

The undersigned Parent(s)/Guardian(s) of the student named herein hereby grant permission for

said student to attend and participate in the following off campus school activity:

Name of Student:__________________________________ D.O.B. ___________________

Activity:__________________________________ Date of Activity: __________________

Location: _______________________________ Teacher/Sponsor:____________________

Method of Transportation: School Bus _____or Private Vehicle _____ or Charter Bus_____

Motor Vehicle Insurance:

I/We understand that under present “no fault” motor vehicle insurance law, if my child is injured

while riding in a private passenger automobile which is involved in an accident, he/she will be

primarily covered for bodily injury under our/my family automobile insurance policy, and I/We

agree to submit any medical bills incurred to my/our insurance company for payment. I/We

assume all responsibility for any deductible or self insured retention which is part of the terms of

my/our motor vehicle insurance personal injury protection coverage.

Assumption of Risk/Release of Liability:

I/We have determined that participation in this off school campus activity by my/our child/ward

is important and is of value and benefit to my/child and ward. I/We understand that the coaching

staff, activity sponsors, teachers and school officials will act reasonable to protect my/our child

from injury, including the provision of appropriate safe equipment, facilities, and training

designed to reduce the possibility of injury or death, and the safety of my/our child is of primary

concern during all such off campus school activities. I/We understand that there will be

incidental stops en-route to and from the activity when determined necessary or desirable. I/We

have considered and know of and acknowledge, and our child/ward has been informed of the

risks involved in said off campus activity, which risks include, but are not limited to, physical

injury, disabling injury and death, and I/We choose to accept any and all responsibility for

his/her safety and welfare while participating in said off campus activity. With full

understanding of the risks involved I/We release and hold harmless my/our child’s/ward’s

school, the School Board of Clay County, Florida (“School Board”) and all officers, employees,

agents and representatives of the School Board and the school from any and all responsibility

and liability for any claim or cause of action for personal injury or death arising out of or

resulting from my child’s/ward’s participation in this activity and agree to take no legal action on

my/our behalf, or on behalf of the child/ward or the estate of the child/ward because of any

injury, death or damage caused by any accident or mishap involving my child/ward while

participating in this activity.

Consent to Medical Treatment/Certification of Physical Condition:

I/We authorize and consent to emergency medical treatment for my/our child/ward

[Parent, Guardian, Student Initial acknowledgement of this page: _____,_____,_____]

Consent And Release From Liability Certificate Template Page 3