Form El2 - Preparticipation Physical Evaluation (Page 2 of 4) in pdf

NOTICE TO PARENTS/GUARDIANS OF MINOR CHILD PARTICIPANTS

READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE

AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY

DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF THE

SCHOOL DISTRICT OF ST. LUCIE COUNTY, ITS OFFICERS,

DIRECTORS, EMPLOYEES, AND AGENTS USE REASONABLE 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 AVOIDED OR

ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR

CHILD’ RIGHT AND YOUR RIGHT TO RECOVER FROM ST. LUCIE

COUNTY SCHOOL DISTRICT IN A LAWSUIT FOR ANY PERSONAL

INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY

DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL

PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN

THIS FORM, AND THE ST. LUCIE COUNTY SCHOOL DISTRICT HAS

THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU

DO NOT SIGN THIS FORM.

I/WE, THE UNDERSIGNED PARENT(S) AND STUDENT PARTICIPANT ACKNOWLEDGE HAVING RECEIVED AN

ADEQUATE OPPORTUNITY TO REVIEW THIS AGREEMENT, PERMISSION, AND RELEASE AND TO ASK QUESTIONS OF

SCHOOL OFFICIALS. I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THIS AGREEMENT; THAT I AGREE TO

ITS TERMS; THAT I WILL COMPLY WITH ALL SCHOOL BOARD AND STATE ASSOCIATION RULES. IT IS UNDERSTOOD

THAT THE STUDENT ATHLETE IS REQUIRED TO COMPLY WITH ALL SAFETY RULES AND INSTRUCTIONS PROVIDE

WITH EACH SPORT, COMPETITION, AND PRACTICE WHILE ENGAGING IN SUCH ACTIVITIES.

I/WE UNDERSTAND THAT PARTICIPATION IN INTERSCHOLASTIC ATHLETICS IS A

PRIVILEGE. FURTHERMORE, WE/I UNDERSTAND THAT THE PRINCIPAL OR DESIGNEE

HAS THE SOLE DISCRETION TO WITHDRAW MY ELIGIBILITY AT ANY TIME DUE TO AN

ON-CAMPUS OR OFF-CAMPUS BEHAVIOR THAT IS DEEMED BY THE PRINCIPAL OR

DESIGNEE TO BE UNBECOMING OF A STUDENT ATHLETE.

------------------------------Acknowledgment of Parent/Guardian Signature)---------------------------------------

Print Parent/Guardian Name _____________________________________ Date _______________

Sign Parent/Guardian Name (In presence of Notary) ______________________________________

STATE OF FLORIDA

COUNTY OF ST. LUCIE

The foregoing instrument was acknowledged before me this _____ day of ______, _______, by

___________________________________.

He/She is ___ personally known to me, or ___ has produced

_____________________________ as identification, and ___ did ___ did not take an oath.

(Notary Seal)

My Commission Expires _______________

Notary Public State of Florida _______________________________________________

Print Notary Name _______________________________________________________

ATH0013 Page 2 of 4

Form El2 - Preparticipation Physical Evaluation Page 2