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Signature
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ELEVATE LIABILITY WAIVER (ENGLISH)
Authorization for Participation, Release of Liability and Authorization for Medical Treatment for Minor Children.
I, the undersigned parent or legal guardian, hereby give permission for (enter student’s full legal name) to participate in the ELEVATE program, the related field trips, and off-campus activities with ELEVATE during the 2026-2027 school year, which includes summer programming. Effective dates for the ELEVATE program and activities would be from August 10th, 2026, through August 9th, 2027.
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Enter Student's Full Legal Name
I give/do not give (select one) permission for ELEVATE staff to access and share with collaborative community partners my student’s school records, including but not limited to: grades, attendance, disciplinary action, and standardized test scores. These records are to be released for statistical purposes, publishable and presentable research, program evaluation, and to assist in the giving of awards.
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I give permission
I do not give permission
I give ELEVATE permission to use my child's image for press releases andadvertising.
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Parent/Guardian Initial
I acknowledge and am aware that participation in ELEVATE involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I understand that participation in ELEVATE activities involves a risk of physical injury. I further release the ELEVATE organization, staff members, directors, officers, and/or volunteers from any and allocations, causes of action, liability, claims, and demands upon any injury, damage, loss, or suffering arising from or related to the aforementioned person’s participation in the above activities.
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Parent/Guardian Initial
I acknowledge that participation involves travel in motor vehicles.
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Parent/Guardian Initial
I acknowledge that participation may include activities involving light physical exertion including, but not limited to: hiking, swimming, camping, and recreational team sports.
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Parent/Guardian Initial
I take full responsibility for any and all expenses incurred for any accidents or injuries, including medical care and related transportation costs, and hold the ELEVATE organization, staff members, directors, officers, and/or volunteers harmless from any costs incurred therein.
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Parent/Guardian Initial
In the event of any emergency, I understand every effort will be made to contact me (and if I’m not available, the alternative person listed below) where medical treatment is required. In the event I cannot be reached, I further authorize the ELEVATE staff or volunteer to render, transport to, or otherwise obtain emergency medical care (including hospitalization, anesthesia, surgery, or injections of medication) or the services of a licensed physician or dentist for the above-named person.
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Parent/Guardian Initial
Emergency Contact:
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Please enter a valid phone number.
Format: (000) 000-0000.
Signature
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Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Personal Health and Medical Information
Student's Full Legal Name
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First Name
Last Name
Date of Birth
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
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Please Select
11
12
13
14
15
16
17
18
19
Sex
Please Select
M
F
Prefer not to say
School Grade
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Please Select
6th
7th
8th
9th
10th
11th
12th
School
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Please Select
Middleton High School
Hillsborough High School
Sligh Middle School
Memorial Middle School
Home Phone
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Name of Parent(s)/Guardian(s)
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Cell Phone
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Lunch/School ID:
General Medical History
(Check all items that apply, past or present, to your health history. Explain all checked.)
Asthma
Allergies
Cancer/Leukemia
Diabetes
Hemophilia
Heart Trouble
High BloodPressure
Kidney Disease
Seizures
Heart Disease
Other
Explain:
Any allergies (food, medicines, insects, environmental, pet, LATEX, drug allergies, etc.)?
Yes
No
Explain:
List any medications you are taking (including non-prescription)
List any physical or behavioral conditions that may affect or limit full participation in swimming, hiking, or playing strenuous physical games or other activities at an outing or camp.
I have carefully read the foregoing release and understand its contents:
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Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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PHOTO RELEASE FORM
From time to time ELEVATE USA may desire to use a picture of your child taken during our events or programs. These pictures may be used for a variety of lawful purposes including press releases, brochures, flyers and web postings. Please complete the photo release form below to allow us to use photos of your child for these purposes.
I agree that ELEVATE USA/TAMPA may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content. I acknowledge that only ELEVATE USA is authorized to use the images. I understand that I may revoke this authorization at anytime except to the extent that action based on this authorization has already taken place. I hereby release ELEVATE USA and its officers from any legal responsibility or liability based on this use of these images. I have read and understand the above: Student Signature
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Full Legal Name
First Name
Last Name
Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
For children under the age of 18: Signature of Parent/Guardian
Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
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