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

STUDENT STATEMENT OF VOLUNATRY PARTICIPATION
AND RELEASE OF ALL CLAIMS

I hereby state that this application to participate is entirely voluntary on my part and is made with the understanding of the following:
The FSA Teen Driver Challenge Training course offered by the Indian River County Sheriff’s Office involves moving vehicles being operated by inexperienced drivers;
I will be operating a vehicle with the express written consent of the owner of the vehicle;
Damage may occur to the vehicle that I am driving or to other vehicles involved in the course; and
My participation in this course subjects me to risk of serious, catastrophic, permanent injury, or even death.

I hereby certify that the vehicle I 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 ME FOR MEDIA COVERAGE, OR FOR ANY OTHER USE DEEMED APPROPRIATE BY THE SHERIFF.

These forms may be signed before either an IRCSO representative OR a notary public, whichever is more convenient.

IRCSO Representative	Student’s Signature
(Witness)

Witness Name Printed	Student 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: