Parental Permission Form And Release Of All Claims (Page 2 of 2) in pdf

Parental Permission Form And Release Of All Claims Page 2

I HEREBY RELEASE AND AGREE TO HOLD HARMLESS FROM LIABILITY FOR ANY AND

ALL CLAIMS, DEMANDS, DAMAGES, ACTIONS, CAUSES OF ACTION, INCLUDING ANY

ACTS OF NEGLIGENCE, OR SUITS IN EQUITY, OF WHATSOEVER KIND OR NATURE,

THE FLORIDA SHERIFFS ASSOCIATION, THE PINELLAS COUNTY BOARD OF COUNTY

COMMISSIONERS, BOB GUALTIERI, SHERIFF OF PINELLAS COUNTY, THEIR OFFICERS,

EMPLOYEES, INSTRUCTORS, AND AGENTS OR APPARENT AGENTS.

I GIVE PERMISSION TO THE PINELLAS COUNTY SHERIFF’S OFFICE TO USE PHOTOGRAPHS

AND/OR VIDEO IMAGES OF MY CHILD FOR MEDIA COVERAGE, OR FOR ANY OTHER USE

DEEMED APPPROPRIATE BY THE SHERIFF.

(These forms may be signed before either a Sheriff’s Office representative OR a notary public, whichever

is more convenient. You must attach copies of your child’s driver’s license and insurance card that would

cover your child operating the vehicle referenced above.)

___________________________

Student signature

___________________________

____________________________

Sheriff’s Office Representative

Parent/Legal Guardian Signature

(Witness)

___________________________

Witness Name Printed

Parent Name Printed

STATE OF FLORIDA

COUNTY OF ____________________

BEFORE ME personally appeared ______________________________, to me well known to be

the person described in and who executed the foregoing instrument, and acknowledged to and before me

that he/she executed said instrument for the purposes therein expressed.

WITNESS my hand and official seal this ____ day of _____________, 20__.

________________________________

NOTARY PUBLIC

Personally known: ______

Provided ______________________________________ as Identification

My Commission expires:

Parental Permission Form And Release Of All Claims Page 2