Completed Incomplete Missing Form: __

Fern Creek High School

2019-2020 Parent Consent & Physical Form

Name: __________ _ Sport: _________ _ Grade:

Table of Contents The following forms must be completed in their entirety and submitted to the coach of the respective sport before the student-athlete is allowed to participate in practice or contests.

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o Must be signed and completed by certified physician; school administered physicals are set for July 15th

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► New KHSAA Physical Form

o Valid for one calendar year; please consider making a personal copy for your own records

► Parent/ Student Concussion Statemento Must be signed by both parent and student-athlete

► JCPS Safety Video Formo Must be signed by both parent and student-athleteo Video is available online via the Team Pages website under the "links" tab

► Fundraising Permission Slipo Must be signed by both parent and student-athlete

► Fern Creek High School Social Media Contract & Rules Agreemento Must be signed by both parent and student-athlete

► JCPS Video Release Formo Must be signed by parent

Required Fees Prior to participation, insurance must be JCPS insurance must be purchased and a physical must be completed. If a physical is done by Fern Creek High School, it needs to be purchased prior to the physical being given. See below for itemization.

Itemized Fees

Physicals = $25.00

Insurance = $20.00 Total = $45.00

Athletic Participation Form

Parental and Student Consent and Release For High School Level (grades 9-12) participation

KHSM Form GE04 High School Parental Permission and

Consent Rev. 1119, page I oil

C KHSAA. 20 I 9

The student and parents/guardian must read this statement carefully and sign where required. By signing this form, all parties agree that they have accurately completed all sections of the form and have read and agree to the terms of this form as detailed. This form must be

completed before the student participates (hereinafter including try out for, practice and/or compete) in interscholastic athletics. This form should be kept in a secure location until the student has exhausted eligibility, graduated from high school and reached the age of 79.

ATHLETE INFORMATION (This part must be completed by the student and family)

Name (Last, First, Initial) Home Address (Street, City, State, Zip):

Gender Date of Birth:

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h I d Sc oo Atten ance History

Grade

School Year

School Birth Place (County, State):

Grade School Name School Year 9

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I am planning t

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articipate in the following (check all you might try to play): aseball Basketball

§ross Country

§ootball

oftball Swimming ennis rack and Field rchery Bass Fishing Bowling Competitive Cheer ther

EMERGENCY CONTACT INFORMATION

§olf olleyball

Dance

Varsity Play -(Yes/No)?

Osoccer [)vrestling

Name (please print) Relation to Student

Emergency Contact Address, including City, State and Zip

Daytime Phone Cell Phone

REQUIRED INSURANCE INFORMATION (KHSAA Bylaw 12)

Prior to participation in practice or contests (including trying for a place on a team) in any sport or sport activity during the limitation of seasons as defined in Bylaw 23, all students are required to have medical insurance with coverage limits of at least $25,000. If this coverage is

provided through the school, contact the Principal or Athletic Director regarding any potential claim. Individual schools and districts may impose additional requirements for insurance or coverage during additional periods for activities outside of Bylaw 23.

Insurance Carrier Policy Number / ID Number Group Number Plan

EMERGENCY TREATMENT INFORMATION The following information is recorded solely for potential hospitalization and emergency care needs and is not required to be recorded on this form. However, those failing to provide this information should be aware that this might be required by emergency treatment facilities prior to rendering service, and failure to provide could result in lack of appropriate care.

Social Security Number Birth Date

CONSENT INFORMATION TO PARTICIPATE, ACKNOWLEDGMENT OF RISK, ACKNOWLEDGEMENT OF ELIGIBILITY RULES, LIABILITY WAIVER AND CONSENT AND RELEASE

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

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��• Shaping the Future

Parent/Guardian Student-Athlete Concussion Statement

I I understand that It Is my responsibility to report all Injuries and Illnesses to my athletlc trainer and/or team physldan. I I have read and understand the Norton Sports Health Concussion Fact Sheet.After reading the concussion fact sheet, I am aware of the following lnfannatlon:

ln1da1Ead1Une

___ A concussion Is a brain Injury, which I am responsible for reporting to my team physldan or athletic

trainer:

___ A concussion can affect my ability to perform everyday activities, and affect reaction time, balance,

sleep, and dassroom performance.

___ You cannot see a concussion, but you might notice some of the symptoms right away. Other

symptoms can show up hours or days after the Injury.

___ If I suspect a teammate has a cancusslan, I am responslble for reporting the Injury to my team

physldan or athletic trainer.

___ I wlll not return to play In a game or practice if I have received a blow to the head or body that

results In concussion-related symptoms.

___ Fotlowlng aconcusslon, the brain needs time lo heal. You are much more likely to have a repeat

concussion If you retum to play before your symptoms resolve.

___ In rare cases, repeat concussions can cause permanent brain damage, and even death.

stgnature of Student-Athlete Date

Printed name of Student-Athlete

Signature of Parent/Guardian Date

Printed name of Parent/Guardian

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Student Name: ------.-:

School: Fern Creek High School ·Sports: ________ _

JEFFERSON COUNTY PUBLIC SCHOOLS SPORTS SAFETY VIDEO FORM

Co�bination Form (Parent and Student)

We certify that we have viewed the JCPS Sports Safety Video in its entirety and understand the contents thereof.

We certify that we will abide by all of the recommendations of the JCPS video.

The part of the video that I thought was most helpful was:

Parent Name (Print)

Student Name (Print)

Fem Creek High Schoo_l __ School

Grade

Date

Parent Signature

Student Signature

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' FUND-RAISING PERMISSION FORM

I, -----�-���-------....iiiiarant permission for (parenVguardian)

_________________ . to participate in fund-raislng (studenrs name)

for the . of Fern Creek High .---------------

(organlzaUon) (".'Jaine of school)

The above named student and I understand that we will be responsible

· for the .reta�I price·(s) of the item(sJ being sold In the �vent all merctiandi�e,. .

and/or funds a·re not returned.

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(parent/guardian signature) (date)

· (home/ceU number)

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4. If you are asked to remove a post, you must do so immediately! This is for the protection ·of your

reputation and that·of FC Football.

In short, do not have a false sense of security about your rights to freedom of speech. Understand that freedom

of speech is not unlimited. The online social network sites are NOT a piace where you can say and do whatever

you want without repercussions. The Information you post on a social networking site Is considered public

Information. Think about who you represent: yourself, your family, your teammates and coaches, and your

school. Like it or not, people are going to associate everything you post with you and what you represent. Protect

yourself by maintaining a self-image of which you can be proud for years to come. By slgnjng this social media

contract, you are stating that you will follow the rules indicated above and you understand that disciplinary

actions may be imposed for failure to comply with those rules.

Student Athlete. _________________ _ Date. ______ _

Parent of Athlete _________________ _ Date ______ _

Also, by signing below, I acknowledge that I fully understand the rule of the Fern Creek Football Program and

agree to follow the rules and expectations as explained above.

Student Athlete ________________ _ Date ______ _

Parent of Athlete ________________ _ Date ______ _

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Jefferson County Public Schools PhotoNideotape Release Form

Throughout the school year, there may be times when Jefferson County Public Schools (JCPS) staff, the

media, or other organizations, with the approval of the school principal, may take photographs of

students, audio/videotape students, or interview students for school related stories in a way that would

individually identify a specific student. Those photographs and/or videotaped images or interviews may

appear in District/School publications, in District/School video productions, on the District/School

website, on District authorized social networking sites such as Facebook or Twitter, in the news media, or

in other organizations' school related stories or articles. To authorize your child's photograph and/or

videotaped image or interview to be used for these purposes, please complete this form and return it to

your child's school.

D I hereby grant unto the Jefferson County Public Schools permission to use my child's,

photograph and/or videotaped image or interview for the purposes mentioned above. I understand and agree that JCPS may use these photos and/or videotaped images or interviews in subsequent school years unless I revoke this authorization by notifying the school principal in writing. I further grant unto the Jefferson County Public Schools permission to permit my child to be photographed, audio/videotaped, or interviewed by the news media or other organizations for school related stories or articles.

Student's Name:

School:

Parent/Guardian Name:

Address:

City/State:

Telephone Number:

Parent/Guardian Signature*:

Fern Creek High School

Zip Code:

Date: ----------------- ------

* Students 18 years of age or older may sign this release form for themselves.

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