Athletic Registration Athletic Registration Step 1 of 7 14% Electronic Signature of Parent/GuardianStudent Last Name*Student First Name*Middle Initial*Grade*789101112DOB* MM DD YYYY Gender*MaleFemaleBirth City*Birth State*Appx. Height*Appx. Weight*Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian #1 Name*Parent/Guardian #2 NameHome Phone Number*Parent/Guardian #1 Cell Phone*Parent/Guardian #2 Cell PhoneParent/Guardian #1 Email* Parent/Guardian #2 Email Email address of athlete* Cell Phone of Athlete* Permission to ParticipatePERMISSION TO PARTICIPATE AND RELEASE Related to Board Policy 9060I, the undersigned parent/guardian hereby grant permission for my child to participate in all athletic teams offered by North Oldham High School EXCEPT the following:*Please type N/A if there are no athletic programs that you wish to not permit your child participate in. Emergency Contact in Event Parent Cannot be Reached*Phone #* Emergency InformationPlease list any health problems/concerns this student may have, including allergies (medications/others) and any medications presently used.*Name of Parent/Guardian* First Last Emergency Phone*REQUIRED INSURANCE INFORMATION (KHSAA BYLAW 12)Insurance Carrier*Policy Number*EMERGENCY CONTACT INFORMATIONName*Relation to Student*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Day Phone*Cell Phone*EMERGENCY TREATMENT INFORMATION:The following information is recorded solely for potential hospitalization and emergency care needs and is not required to be recorded in 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. Date of birth* MM DD YYYY The student and parents/guardian must read this statement carefully and sign where required. This form must be completed before the student participates (hereinafter; including try out for, practice, and/or complete) 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 19. Student Signature* Insurance WaiverThe Kentucky High School Athletic Associate requires that a reputable company insure each participant. You have the option of selecting the Scholastic Insurer plan offered through the school insurance program or waive the school insurance in favor of you family policy (item 2 section A or C). If you select the waiver clause, you are indicating that your insurance will be responsible for covering any medical cost or expenses that arise rather than the North Oldham High School or Oldham County Board of Education. If you select the Scholastic Insurers coverage, it will be necessary for you to purchase school insurance. You child must have school insurance or be covered by your family policy in order to participate in athletics at North Oldham High School.Please check one of the following: We wish to purchase the social insurance uner Scholastic Plan We have already purchased the Scholastic insurers school insurance Waive Clause Alternative Transportion ConsentRelated to Board Policy 8005 Related to 8005-AR;8005.01-FThe Oldham County Board of Education offers a broad range of sports and extracurricular activities to students enrolled in middle and high school. This broad range of activities places constraints on the ability of the district to provide transportation for all these activities at all times. As a result, there are events, practices and extra-curricular activities that will require the student's parent to arrange transportation to and/or from the event or activity. The coach or activity sponsor will provide information regarding the level of transportation provided by the district. Name of School*Grade*Sport/Extracurricular*Season*The district will provide transportation to events, game and activities in accordance with 8005-AR. When the district is unable to provide transportation to events, game and activities, I consent to the following means of transportation for my child (Check all that Apply):*Van/Automobile driven by team coach/activity sponsor.Automobile driven by another parent for whom I have provided.Automobile Driven by my Student.None. I will be responsible for transporting my child to and from events.In consideration of the advantages to my child of participating in this sport or extracurricular activity, to the extent allowable by law I hereby release and hold harmless the Oldham County Board of Education, its members, employees, agents, representatives and insurers, and the School and its employees and agents from any liability for bodily injury or death resulting from said transportation. I sign this consent and release individually and on behalf of my student. * I give my student permission to ride the Oldham County bus to away athletic events. I give my child permission to be transported by the following adults: List Click the + to add addtional names. Student must have proof of private insurance or student accident insurance to participate in co-curricular or extra-curricular activities or field trips away from school. In consideration of the advantages of participation in this field trip, the undersigned agrees that the Board of Education of Oldham County, Kentucky, its agents and employees, and the driver and/or owner of the vehicle used for the field trip shall be released and exxempt from liability for damages for bodily injury or property damage that may occur during the trip, as provided by law. To Whom It May Concern: We (I), as Parents(s) of:* do hereby authorize and direct the staff of Oldham County Schools to initiate the procedures deemed necessary by medical personnel to act in our child's behalf and agree to "Hold Them Harmless" for any treatment rendered. Please orovide a current phone number and alternative contact number for the date of the trip. Adopted: March 16, 1981 Revised: July 17, 1983 Revised: February 22, 1993 Revised: February 10, 1998 Revised: August 15, 1998 Revised: September 1, 1998 Revised: June 23, 1999 Revised: July 14, 2000 Revised: June 26, 2006 Revised: July 16, 2008 Oldham County Board Of Education Administrative RegulationCONSENT OF PARENT OR GUARDIAN FOR ImPACT TESTING OF HIGH SCHOOL STUDENT ATHLETESHigh School:* North Oldham Oldham County South Oldham High School:* Senior Junior Sophomore Freshman 8th 7th 6th I hereby give permission for my child to complete an ImPACT baseline test and post-concussion ImPACT tests administered at the high school for which my student is competing as needed. I understand that my child may need to complete the test more than once, depending on the results of the test. I understand the is no charge for the testing.I further agree that the high school may release the ImPACT results and any other information related to his or her head injury to my child's primary care physician, neurologist, or other physician involved with my child's care.Electronic Signature of Parent/Guardian*Preferred Phone Contact Method:* Home Work Cell Please contact me about North Oldham High School's digital products. Email I _____________(electronic signature) have completed and agree to all of the items found in the forms of the Athletic Registration Packet.