Indian River County Sheriff’s Office and The Florida Sheriff’s Association
Teen Driver Challenge

PARENTAL PERMISSION FORM AND RELEASE OF ALL CLAIMS

STUDENT INFORMATION

Name of Student:   		Age:   		
Date of Birth:   			
Driver’s License Number:   		State:   		
Current Address:   	
City: 	State: 	Zip:   	

Name of School Currently Attending: 		Grade:   	

Name of Parents or Legal Guardian:   	
Medical Insurance Provider: 		Policy Number:   	

Home Telephone Number:   	 Emergency Contact Name:   	 

Cell Phone Number:   	 Number:   	 

Are there any health issues we should be aware of including allergies?
YES	NO	If YES, Explain: 	 Is any medication being taken that will in any way effect the safe operation of a vehicle?
YES	NO	If YES, Explain:   	
Shirt Size: 		Date of the class requested:   	

How did you hear about the class?  	
I have been informed that my child’s full name, address, date of birth, and driver’s license number will be released to the Florida Sheriffs Association Teen Driver Challenge upon request.

I hereby give my consent for the above-named student to participate in the FSA Teen Driver Challenge offered by the Indian River County Sheriff’s Office.

I state this consent is given with the understanding that:

The training course involves moving vehicles being operated by inexperienced drivers.
The above-named student will be operating a vehicle with the express written consent of the owner of the vehicle.
Damage may occur to the vehicle that the above-named student is driving or to other vehicles involved in the course.
The above-named student’s participation in this course subjects the student to a risk of serious, catastrophic, permanent injury, or even death.
If I am not the owner of the vehicle which the above-named student intends to use while taking this course, I hereby certify that the owner has consented to the use of his/her vehicle and has authorized      the use by

completing the VEHICLE OWNER’S STATEMENT OF PERMISSION AND RELEASE OF ALL
CLAIMS attached. I certify that the vehicle which the above-named student will use in this course is in good working order, including the vehicle’s engine, brakes, suspension, steering and tires.

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 INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS, THE TREASURE COAST PUBLIC SAFETY TRAINING COMPLEX OF INDIAN RIVER STATE COLLEGE, THE INDIAN RIVER COUNTY SCHOOL DISTRICT, THE INDIAN RIVER COUNTY SHERIFF’S OFFICE, THE SHERIFF, EMPLOYEES, INSTRUCTORS, AGENTS OR APPARENT AGENTS, AND OTHER PARTICIPANTS IN THE COURSE.

I GIVE PERMISSION TO THE INDIAN RIVER 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 an IRCSO representative OR a notary public, whichever is more convenient.)

			
IRCSO Representative		Parent/Legal Guardian Signature	
(Witness)			
			
Witness Name Printed		Parent Name Printed	

STATE OF FLORIDA COUNTY OF INDIAN RIVER

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: