Khsaa Athletic Participation - Physical Examination Form - Consent And Release 2009 (Page 3 of 4) in pdf

KHSAA Form GE04 Part 1, Physician and Parental Permission, Rev. 4/09, page 3 of 4

PART IV - EMERGENCY PERMISSION FORM

(This part must be completed by student and custodial parent / guardian)

STUDENT NAME ____________________________________________________________________________________________

SOCIAL SECURITY NUMBER ___________________________________________________________________________________

ADDRESS _________________________________________________________________________________________________

CITY/STATE/ZIP _____________________________________________________________________________________________

SCHOOL __________________________________________________________________________________________________

BIRTH DATE _______________________________________________________________________________________________

PHONE ___________________________________________________________________________________________________

PERSON TO CONTACT IN CASE OF MEDICAL EMERGENCY:

NAME____________________________________________________________________________________________________

RELATION_________________________________________________________________________________________________

ADDRESS _________________________________________________________________________________________________

CITY/STATE/ZIP _____________________________________________________________________________________________

DAYTIME PHONE ___________________________________________________________________________________________

EVENING PHONE ___________________________________________________________________________________________

Please list any health problems/concerns your child may have, including allergies (medications / others) and any medications presently being

used: _______________________________________________________________

Students desiring to participate in Wrestling must also complete KHSAA Form WR101 and required attachments between October 15 and

the first contest.

This form must be reproduced in order for a copy to travel with respective athlete.

PART V – CONSENT TO PARTICIPATE, ACKNOWLEDGMENT OF RISK, ACKNOWLEDGEMENT OF ELIGIBILITY RULES, LIABILITY

WAIVER AND CONSENT AND RELEASE

The student and parents/guardian must read this statement carefully. This form must be completed before the student participates

(hereinafter including try out for, practice and/or compete) in interscholastic athletics.

As parent/legal guardian, I agree to allow my child to participate in interscholastic athletics.

The student and parent/legal guardian recognize that participation in interscholastic athletics involves some inherent risks for potentially

severe injuries, including but not limited to death, serious neck, head and spinal injuries which may result in complete or partial paralysis,

brain damage, serious injury to virtually all internal organs, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other

aspects of the muscular skeletal system, and serious injury or impairment to other aspects of the body, or effects to the general health and

well being of the child. Because of these inherent risks, the student and parent/legal guardian recognize the importance of the student

obeying the coaches’ instructions regarding playing techniques, training and other team rules. By signing this form, the student and

parent/legal guardian acknowledge that the student’s participation is wholly voluntary and to having read and understood this provision.

The student and parent/legal guardian individually and on behalf of the student, hereby irrevocably, and unconditionally release, acquit, and

forever discharge the KHSAA and its officers, agents, attorneys, representatives and employees (collectively, the “Releasees”) from any and all

losses, claims, demands, actions and causes of action, obligations, damages, and costs or expenses of any nature (including attorney’s fees)

that the student and/or parent/legal guardian incur or sustain to person, property or both, which arise out of, result from, occur during or are

otherwise connected with the student’s participation in interscholastic athletics if due to the ordinary negligence of the Releasees.

The student and parent/legal guardian acknowledge that they have read and understood the KHSAA Bylaws 1 through 33 by distribution

through the member school or by review at Please be aware that a student is subject to the one

year period of ineligibility in Bylaw 6, otherwise known as the "Transfer Rule," upon participation in any varsity contest

regardless of the amount of participation or lack thereof.

The student and parent/legal guardian agree to abide by the KHSAA Bylaws and Due Process Procedure as now enacted or later amended.

The student and parent/legal guardian further acknowledge that they agree to abide by the rulings of the Commissioner, Assistant

Commissioner, Hearing Officer and Board of Control.

The student and parent/legal guardian acknowledge that the student must have insurance coverage up to a limit of $25,000 in order to be

eligible to participate in interscholastic athletics.

Khsaa Athletic Participation - Physical Examination Form - Consent And Release 2009 Page 3

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