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EL3

Florida High School Athletic Association

Revised 05/12

Consent and Release from Liability Certificate

(Page 1 of 2)

This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the most recent signature.

Part 1. Student Acknowledgement and Release

(to be signed by student at the bottom)

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 interscholastic athletic competition. If accepted as a representative, I agree to follow the rules of my school and 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, including the potential

for a concussion, 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 parent(s)/

guardian(s), I hereby release and hold harmless my school, the schools against which it competes, the school district, the contest officials and 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 FHSAA because of any accident or

mishap involving my athletic participation. I hereby authorize the use or disclosure of my individually identifiable health information should treatment for illness or injury

become necessary. I hereby grant to FHSAA the right to review all records relevant to my athletic eligibility including, but not limited to, my records relating to enrollment

and attendance, academic standing, age, discipline, finances, residence and physical fitness. I hereby 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, promotional and commercial materials without

reservation or limitation. The released parties, however, are under no obligation to exercise said rights herein. I understand that the authorizations and rights granted herein

are voluntary and that I may revoke any or all of them at any time by submitting said revocation in writing to my school. By doing so, however, I understand that I will

no longer be eligible for participation in interscholastic athletics.

Part 2. Parental/Guardian Consent, Acknowledgement and Release

(to be completed and signed by a parent(s)/guardian(s) at the

bottom; where divorced or separated, parent/guardian with legal custody must sign.)

EXCEPT

I hereby give consent for my child/ward to participate in any FHSAA recognized or sanctioned sport

for the following sport(s):

__________________________________________________________________________________________________________________________________

List sport(s) exceptions here

I understand that participation may necessitate an early dismissal from classes.

I know of, and acknowledge that my child/ward knows of, the risks involved in interscholastic athletic participation, understand 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 release and hold harmless my child’s/ward’s school, the schools against which it competes, the school district, the contest officials and 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 FHSAA because of any ac-

cident or mishap involving the athletic participation of my child/ward. I authorize emergency medical treatment for my child/ward should the need arise for such treatment

while my child/ward is under the supervision of the school. I further hereby authorize the use or disclosure of my child’s/ward’s individually identifiable health information

should treatment for illness or injury become necessary. I consent to the disclosure, by my child’s/ward’s school, to the FHSAA, upon its request, of all records relevant

to his/her athletic eligibility including, but not limited to, his/her records relating to enrollment and attendance, academic standing, age, discipline, finances, residence and

physical fitness. I grant the released parties the right to photograph and/or videotape my child/ward and further to use said child’s/ward’s name, face, likeness, voice and

appearance in connection with exhibitions, publicity, advertising, promotional and commercial materials without reservation or limitation. The released parties, however,

are under no obligation to exercise said rights herein.

I am aware of the potential danger of concussions and/or head and neck injuries in interscholastic athletics. I also have knowledge about the risk of continuing to

participate once such an injury is sustained without proper medical clearance.

READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR

MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREE-

ING THAT, EVEN IF MY CHILD’S/WARD’S SCHOOL, THE SCHOOLS AGAINST WHICH IT

COMPETES, THE SCHOOL DISTRICT, THE CONTEST OFFICIALS AND FHSAA USES REA-

SONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY

BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE

THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOID-

ED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD’S RIGHT

AND YOUR RIGHT TO RECOVER FROM MY CHILD’S/WARD’S SCHOOL, THE SCHOOLS

AGAINST WHICH IT COMPETES, THE SCHOOL DISTRICT, THE CONTEST OFFICIALS

AND FHSAA IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR

CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NAT-

URAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM,

AND MY CHILD’S/WARD’S SCHOOL, THE SCHOOLS AGAINST WHICH IT COMPETES, THE

SCHOOL DISTRICT, THE CONTEST OFFICIALS AND FHSAA HAS THE RIGHT TO REFUSE

TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.

I agree that in the event we/I pursue litigation seeking injunctive relief or other legal action impacting my child (individually) or my child’s team participation in

FHSAA state series contests, such action shall be filed in the Alachua County, Florida, Circuit Court.

I understand that the authorizations and rights granted herein are voluntary and that I may revoke any or all of them at any time by submitting said revocation in

writing to my school. By doing so, however, I understand that my child/ward will no longer be eligible for participation in interscholastic athletics.

Please check the appropriate box(es):

____ My child/ward is covered under our family health insurance plan, which has limits of not less than $25,000.

Company: ____________________________________________________________ Policy Number: ________________________________

____ My child/ward is covered by his/her school’s activities medical base insurance plan.

____ I have purchased supplemental football insurance through my child’s/ward’s school.

I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE (Only one parent/guardian signature is required)

__________________________________________________

____________________________________________________

_______/_______/____________

Name of Parent/Guardian (printed)

Signature of Parent/Guardian

Date