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

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

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

WAIVER AND CONSENT AND RELEASE (continued)

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.

The student and parent/legal guardian consent to this student receiving a physical examination as required by the KHSAA.

The student and parent/legal guardian, individually and on behalf of this student, give the high school, the KHSAA and their representatives

permission to release this student’s demographic information (including motion picture and still photography) and participation statistics

(including height, weight and year in school, participation history) and other information as may be requested, and agree that the student may

be photographed or otherwise digitally or electronically captured during school-based competition and such image or other report may be

used without permission or compensation.

The student and parent/legal guardian, individually and on behalf of this student, consent to the high school and the KHSAA and their

representatives to use and disclose the necessary personally identifiable information from the student’s education records including academic,

financial and health care information, to third parties including school representatives, coaches, athletic trainers, medical facilities, medical

staffs, KHSAA legal counsel and the media, for the purpose of receiving proper/necessary medical care and complying with the KHSAA bylaws,

including making determinations regarding eligibility to participate in interscholastic athletics and any administrative or legal proceedings

resulting from participation or attempted participation in interscholastic athletics, without such disclosure constituting a violation of my rights

under the Family Educational Rights and Privacy Act. I further release the high school, the KHSAA and their representatives from any and all

claims arising out of the use and disclosure of said necessary personally identifiable information. I also agree to release to the high school, the

KHSAA, and their representatives, upon request, the detailed and completed application for financial aid.

The student and parent/legal guardian, individual and on behalf of the student, hereby consent to allow the student to receive medical

treatment that may be deemed advisable by the high school, the KHSAA, and their representatives in the event of injury, accident or illness

while participating in interscholastic athletics, including, but not limited to, transportation of the student to a medical facility.

Students’ Name (please print)

School

Student and Parent/Guardian Address

Signature of Student

Date

Name of Parent(s)/Guardian(s) who has/have custody of this student (please print)

Emergency Phone Number

Signature of Parent(s)/Guardian(s) who has/have custody of this student

Date

Insurance Carrier

Policy Number

Khsaa Athletic Participation - Physical Examination Form - Consent And Release 2009 Page 4