Form El2 - Preparticipation Physical Evaluation printable pdf download

SCHOOL BOARD OF ST. LUCIE COUNTY, FLORIDA

MIDDLE SCHOOL INTRAMURAL, PERMISSION, AND RELEASE

Name of Student Participant (Please print)

Home Address

Home Phone

____________ Date of Birth

Place of Birth

Parent/Guardian Work Phone

Other Emergency /Cell Phone

School _____________________________ Grade Level ____________ Sport(s) ___________

/We, the undersigned Parent(s)/Guardian(s) of the above named student, acknowledge that participating in middle

school intramurals in the St. Lucie County Schools is entirely voluntary and subject to the rules and policies of the St.

Lucie County School District. I understand that my child must abide by all the rules set down by the School Board of

St. Lucie County and the school in which the Student Participant is enrolled (School). All infractions of the Code of

Student Conduct shall be reported to school administration. All infractions are subject to the appropriate Discipline

Response as defined in The School Board of St. Lucie County Code of Student Conduct.

Student participants and parents or guardians of Student participants should have a thorough understanding of the

responsibilities and implications of participating in a voluntary extracurricular activity. For this reason, each Student

Participant in the St. Lucie County Schools and his/her parent(s), or guardian(s), shall read, and sign this agreement,

permission, and release prior to the Student Participant being allowed to participate in any form of intramural practice

or contests.

I/We, the undersigned Parent(s)/guardian(s) of the above name Student Participant:

1. Understand that I must have a current physical on file at the school and a completed permission and release

form.

2. Understand that only a supplementary insurance premium for the Student Participant is to be paid from school

board funds. This insurance will have a $500.00 deductible. This deductible will be applied concurrent with

primary coverage which will be paid at 100% Reasonable and Customary. If there is no primary coverage, this

insurance will pay 100% of Reasonable and Customary after the $500.00 deductible.

3. Understand that a TWENTY DOLLAR ($20.00) NON-REFUNDABLE PROCESSING FEE must be paid when

this form is submitted. This fee does guarantee participation in the Intramural program at the school your child

attends; however it does not guarantee selection to a tournament team. I also understand that additional

fees may be assessed to participate in a specific sport due to financial limitations and the uncertainty of financial

times.

4. Understand that in the event of accident or injury, only School required accident forms will be completed by

School officials, and that all claims under any applicable insurance policy for injuries received while participating

in intramural activities or travel incidental to such activities shall be processed by the Parent(s)/guardian(s) or the

student participant through the company agent handling the insurance policy, and not through School officials.

5.. Authorize the School to transport the Student Participant and to obtain, through a physician of the School's

choice, any emergency medical care that may become reasonably necessary for the student in the course of

intramural activities or travel incidental to such activities; and agree that the expenses for such transportation and

treatment shall not be borne by the School Board or its employees.

6. I understand that talking to a coach or someone from any high school about playing at

his/her school before you begin attending that school is a violation and could result in:

(FHSAA Policy 36)

You being ineligible for a year;

The coach may be fined and suspended;

The school may face penalties including fines and not making the playoffs.

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Form El2 - Preparticipation Physical Evaluation

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