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.  

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. 

• 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.

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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. 

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

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.