2011 - 2012 Consent, Authorization and Release Form

1. I hereby give my consent for , Male Female , grade 6 7 8 9 10 11 12 , to participate in Tampa Preparatory School athletic activities, school sponsored or classroom sponsored field trips (including, but not limited to, travel to and from said activities) and in other activities that are part of the expanded Tampa Prep program. It is my clear understanding that participation in athletic or other activities creates a risk normally associated with such activities, including the potential for catastrophic injury or even death. I indemnify and agree not to hold the School or anyone acting on its behalf, responsible for any injury or damage occurring to the above named student, others, or property in the course of either athletic or other school program activities.

2. I hereby consent and authorize the School to send transcripts, test results and recommendations to colleges, universities and scholarship programs. Colleges and other academic programs that receive transcripts require the student's Social Security number. Please provide your child's Social Security number: .

3. I hereby give permission to Tampa Preparatory School to use my child’s image, whether by video, photograph, or otherwise, name/identity and voice in school publications, the school’s web site, chronicles of school activities or events and/or other school publicity including media interviews.

4. I hereby give permission for Tampa Prep’s trained staff to administer appropriate medical attention including, but not limited to, first aid treatment and other services, and I authorize the School to obtain a physician of its own choice for any emergency medical care that may become reasonably necessary for my child in the course of athletic activities, field trips or a normal school day. In the event of an emergency, as determined by the School, every effort will be made to contact the student’s family; however, medical help will be sought as quickly as possible. Please provide us with complete and accurate medical information so that we may respond appropriately in an emergency. Information provided will be kept confidential within the student’s medical file. If this information changes at any time please notify us immediately.

5. I hereby give permission for Tampa Prep’s psychologist to speak with my child when referred by a staff member, a student, or self-referred (parent/student themselves). The psychologist will fully evaluate the situation and assess the need for referral to further outside therapy if appropriate. Student confidentiality will be maintained unless 1) the student is a threat to himself/others, or 2) reporting is required by law, and 3) student and parent consent. No therapy is performed on the school premises; the psychologist focuses on problem-solving as well as other social skills (i.e. self-esteem, test anxiety) as it relates to human development. The psychologist informs each student of this policy upon meeting.

• My child is currently taking the following medications:
  List all or write NONE


• My child suffers an allergic reaction to the following medications/substances:
  List all or write NONE


• Please list ALL existing medical conditions:
  List all or write NONE

My child may be given: (Please check approved over-the-counter meds.)
Acetaminophen (Tylenol)
Ibuprofen (Advil)
Benadryl
Midol
Other

By this authorization, I indemnify, release and hold Tampa Preparatory School harmless from any and all liability in providing care and treatment to my child, and further, I grant my permission regarding use of the above information.

Statement of voluntary athletic participation: My participation in interscholastic athletics for Tampa Preparatory School is entirely voluntary on my part and is made with the understanding that I have not violated any of the eligibility rules and regulations of the Florida High School Athletic Association.