Consent Form for Ages Under 18

SKATE PARK PARENTAL CONSENT FORM

THE UNDERSIGNED, as the parent/guardian of ____________________________________ (hereinafter “Child”), hereby give my consent to the City of Zephyrhills, Florida to allow my Child to utilize the City’s public skate park. I hereby acknowledge the risks and dangers associated with the activities conducted at these facilities by the participants, and I do voluntarily accept and assume those risks and hold the City harmless from any death or bodily injury to my Child. I fully understand and agree that the City of Zephyrhills shall not be liable in any way for injury to, or the death of, any person, including my Child, involved in activities performed at this park. This consent shall remain in full force and effect unless revoked by me in writing.

________________________________________       ____________________________________
Parent/guardian signature                                              Print name

____________________________________
Parent / guardian driver’s license number                         

________________________________________      ____________________________________
Address                                                                         City, State, Zip Code

_____________________________                              ______________________________
Home Phone Number                                                     Emergency Contact Phone Number

COUNTY OF PASCO
STATE OF FLORIDA

BEFORE ME appeared ___________________________________ who is the parent or legal guardian of the above-named child and who acknowledged that he/she has read the parental consent form and Skate Park Policies and Guidelines, and freely agrees to abide by same. __________________________________ is _____ personally known to me, or _____ has produced the following identification: _____________________________________________.                               .

________________________________________
Notary Public

Printed Name: ________________________________________                                             

My Commission Expires:  _______________________________

Date: _______________________________________________