Miami-Dade County Public Schools Middle School Athletic Program Consent and Release from Liability Certificate

This completed form must be kept on file by the school. This form is valid until June 30th of the current school year.

Part 1. Student Acknowledgement and Release (to be signed by student at the bottom)

I have read the Eligibility Rules of this “Consent and Release Certificate” and know of no reason why I am not eligible to represent my school in middle school athletic competition. If accepted as a representative, I agree to follow the rules of my school 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 middle school athletics, with full understanding of the risks involved. I hereby release and hold harmless my school, the schools against which it competes, The School Board of Miami-Dade County, Florida, its representatives, officers, directors, administrators, employees, agents, and the contest officials 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 School Board of Miami-Dade County, Florida, its representatives, officers, directors, administrators, employees, or agents 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.

Part 2. Parental/Guardian Consent, Acknowledgement and Release (to be completed and signed by a parent(s)/guardian(s) at the bottom of this form; where divorced or separated, parent/guardian with legal custody must sign

A. I hereby give consent for my child/ward to participate in any recognized or sanctioned middle school sport EXCEPT for the following sport(s):

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

C. I know of and acknowledge that my child/ward knows of the risks involved in middle school 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 middle school 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 Board of Miami-Dade County, Florida, its representatives, officers, directors, administrators, employees, agents, and the contest officials 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 school district because of any accident 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 to Miami-Dade County Schools Middle School Athletic Program (MSAP), by my child’s/ward’s school, upon 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.

D. I am aware of the potential danger of concussions and/or head and neck injuries in middle school athletics. I also have knowledge about the risk of continuing to participate once such an injury is sustained without proper medical clearance.

E. 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 child’s/ward’s school. By doing so, however, I understand that my child/ward will no longer be eligible for participation in middle school athletic competition.

Your school is a member of the Miami-Dade County Schools Middle School Athletic Program (MSAP) and follows established g rules. To be eligible to represent your school in middle school athletics, in a sport (i.e. basketball, bowling, cross country, fla football, golf, soccer, softball, swimming, tennis, track & field, volleyball and wrestling), the student:

1. Must be regularl y enrolled and in regular attendance at your school.

2. A seventh or eighth grade student must have earned at least a 2.0 grade point average and a 2.0 in conduct on 4.0 unweighted scale the previous grading period.

3. Six graders must have a 2.0 GPA after the first two grading periods.

4. Must have signed permission to participate from the student’s parent(s)/guardian(s) on bottom of this form.

5. A student who reaches the age of 15 on or after September 1st may participate in interscholastic athletics during that school year.

6. Must display good sportsmanship and follow the rules of competition before, during and after every contest in which the student participates. If not, the student may be suspended from participation for a period of time.

7. Must not provide false information to his/her school to gain eligibility.

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 MY CHILD’S/WARD’S SCHOOL, THE SCHOOLS AGAINST WHICH IT COMPETES, THE SCHOOL BOARD OF MIAMI DADE COUNTY, FLORIDA, ITS REPRESENTATIVES, OFFICERS, CHILD’S/WARD’S SCHOOL, DIRECTORS, ADMINISTRATORS, EMPLOYEES, AGENTS, AND THE CONTEST OFFICIALS 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’S RIGHT AND YOUR RIGHT TO RECOVER FROM MY CHILD’S/WARD’S SCHOOL, THE SCHOOLS AGAINST WHICH IT COMPETES, THE SCHOOL BOARD OF MIAMI-DADE COUNTY, FLORIDA, ITS REPRESENTATIVES, OFFICERS, DIRECTORS, SCHOOL BOARD OF MIAMI-DADE COUNTY, FLORIDA, ITS REPRESENTATIVES, OFFICERS, DIRECTORS, ADMINISTRATORS, EMPLOYEES, AGENTS, AND THE CONTEST OFFICIALS HAVE THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.

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

I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE (student must sign)