Ihsaa Pre Participation Physical Evaluation Form (Page 4 of 4) in pdf

CONSENT & RELEASE CERTIFICATE

I. STUDENT ACKNOWLEDGMENT AND RELEASE CERTIFICATE (to be signed by student)

I have read the IHSAA Eligibility Rules (next page or on back) and know of no reason why I am not eligible to represent my school in athletic

competition.

If accepted as a representative, I agree to follow the rules and abide by the decisions of my school and the IHSAA.

I know that athletic participation is a privilege. I know of the risks involved in athletic participation, understand that serious injury, 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 athletics, with full understanding of the risks involved, and agree to release and hold harmless my school, the

schools involved and the IHSAA of and from any and all responsibility and liability, including any from their own negligence, for any injury or

claim resulting from such athletic participation and agree to take no legal action against my school, the schools involved or the IHSAA because

of any accident or mishap involving my athletic participation.

I consent to the exclusive jurisdiction and venue of courts in Marion County, Indiana for all claims and disputes between and among the IHSAA

and me, including but not limited to any claims or disputes involving injury, eligibility or rule violation.

I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE PROVISION.

Date: ____________________Student Signature: _____________________________________________________

Printed: _____________________________________________________

II. PARENT/GUARDIAN/EMANCIPATED STUDENT CONSENT, ACKNOWLEDGMENT AND RELEASE CERTIFICATE

(to be completed and signed by all parents/guardians, emancipated students; where divorce or separation, parent with legal custody must sign)

I/we hereby give consent for my son/daughter/me to participate in the following interschool sports not marked out:

Boys Sports: Baseball, Basketball, Cross Country, Football, Golf, Soccer, Swimming, Tennis, Track, Wrestling.

Girls Sports: Basketball, Cross Country, Golf, Gymnastics, Soccer, Softball, Swimming, Tennis, Track, Volleyball.

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

I/we consent to the disclosure, by my son’s/my daughter’s/my school, to the IHSAA of all requested, detailed financial (athletic or otherwise),

scholastic and attendance records of such school concerning my son/daughter/me.

I/we know of and acknowledge that my son/daughter knows of the risks involved in 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/my safety and welfare while participat-

ing in athletics. With full understanding of the risks involved, I/we release and hold harmless my/our school, the schools involved and the

IHSAA of and from any and all responsibility and liability, including any from their own negligence, for any injury or claim resulting from such

athletic participation and agree to take no legal action against the IHSAA or the schools involved because of any accident or mishap involving

my son’s/my daughter’s/my athletic participation.

I consent to the exclusive jurisdiction and venue of courts in Marion County, Indiana for all claims and disputes between and among the IHSAA

and me and/or my child, including but not limited to any claims or disputes involving injury, eligibility, or rule violation.

Please check the appropriate space:

The student has school student accident insurance.

The student has football insurance through school.

The student has adequate family insurance coverage.

Company:

Policy Number:

I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE PROVISION.

Date: ____________________Parent/Guardian/Emancipated Student Signature:__________________________________________________

Printed: _____________________________________________________

Date: ____________________Parent/Guardian/Emancipated Student Signature:__________________________________________________

Printed: _____________________________________________________

CONSENT & RELEASE CERTIFICATE

Indiana High School Athletic Association, Inc.

9150 North Meridian St., P.O. Box 40650

Indianapolis, IN 46240-0650

This form should be filed in the appropriate office designated by each particular school.

Separate Form Required for Each School Year

FORM D - 3/07

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Ihsaa Pre Participation Physical Evaluation Form Page 4

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