1. education
2. school

Louisville duPont Manual High School
David Zuberer
Athletic Director
120 West Lee Street
Louisville, KY 40208
Athletic Office: (502) 485-8489
School Office: (502) 485-8241
School Fax: (502) 485-8035
2014-15 STUDENT INSTRUCTIONS
FOR INITIAL ATHLETIC PARTICIPATION
REQUIRED FORMS/FEES & COLLECTION DATES
The following forms and fees must be submitted completed in their entirety to Manual’s athletic office prior to the
beginning of the student’s athletic participation (due dates listed at the bottom of this page). Students must be marked
“CLEARED TO PARTICIPATE” on the following website 14-15 Paperwork/Fee Checklist for Athletic Participation.
•
KHSAA Physical Form
o physicals are valid for one calendar year from date of examination
o must be signed as “cleared to participate” by physician
•
JCPS Addendum to the Physical
o must be signed by physician
•
Parent / Student-Athlete Concussion Statement
o Concussion Reference Card is available on school website under “Sports Forms”
•
JCPS Parent Permission/Release Form
o must be notarized
•
JCPS Safety Video Signature Form
o must be signed by parent and student
o video is available on school website under “Sports Links”
•
Transportation Waiver
o must be notarized
•
Parent Communication Agreement Form
•
Social Networking Agreement
o must be signed by parent and student
•
JCPS Photo/Videotape Release Form
REQUIRED FEES
Each student-athlete is required to pay the insurance/trainers fees listed below to participate. Student-athletes pay this
fee one time per school year. Make checks payable to Manual High School.
CUT SPORTS
Tryout Fee $5.00
Make Team - $35.00
Total $40.00
NON-CUT SPORTS
Total - $40.00
Please make sure all forms are submitted by the dates listed below:
FALL SPORTS – All forms and fees submitted by June 20, 2014
WINTER SPORTS – All forms and fees submitted by October 3, 2014
SPRING SPORTS – All forms and fees submitted by February 6, 2015
SPIRIT TEAMS – All forms and fees submitted 2 weeks prior to tryout date
Physician and Parental Permission
KHSAA Form GE04, Rev. 5/12, page 1 of 4
KENTUCKY HIGH SCHOOL ATHLETIC ASSOCIATION
2280 Executive Drive, Lexington, Kentucky 40505
Athletic Participation/Physical Examination Form/Consent and Release
PART I - ATHLETE INFORMATION
(This part must be completed by the student)
Name (Last, First, Initial)
Home Address (Street, City, State, Zip):
Gender
Grade
Date of Birth:
Attendance History
Grade
School Name
9
10
11
12
School Year
School
Birth Place (County, State):
School Year
Varsity Play – (Yes/No)?
I am planning to participate in the following (circle all you might try to play):
Baseball
Basketball Cross Country
Football
Golf
Soccer
Softball
Swimming Tennis
Track and Field Volleyball
Wrestling
Archery Bass Fishing
Bowling
Cheer
Other
PART II - MEDICAL HISTORY
Parent and student complete this part and present to the authorized health care provider before the physical.
CHECK THE APPROPRIATE RESPONSE TO EACH ITEM:
YES NO
1.
Have you ever been hospitalized?
2.
Have you ever had surgery of any kind (e.g., tonsillectomy).
3.
Are you presently taking any medications or pills?
4.
Do you have any allergies (medicine, bees, or other insects)?.
5.
Have you ever passed out during exercise?
6.
Have you ever been dizzy during or after exercise?
7.
Have you ever had chest pain during or after exercise?
8.
Have you ever had high blood pressure?
9.
Have you ever been told you have a heart murmur?
10. Have you ever had racing of your heart?
11. Has anyone in your family died of heart problems before 50?.
12. Do you have any skin problems? (itching, rashes, acne)
13. Have you ever had a head injury?
14. Have you ever been knocked out or unconscious?
15. Have you ever had a seizure or suffer from epilepsy?
16. Have you ever had a stinger, burner or pinched nerve?
17. Have you ever had heat related problems?
18. Have you ever been dizzy or passed out in the heat?.
19. Do you cough heavily, or breath heavily during activity?
20. Do you use any special equipment (e.g., knee brace)?
21. Have you had any problems with your eyes or vision?.
22. Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other
injuries of any bones?
23. Are you missing one of any paired organs (e.g., eyes)
24. Have you ever been diagnosed with any form of asthma?
25. Are you using an inhaler for asthma?
26. Are you diabetic?
27. Do you administer insulin to yourself?
28. Are you presently using tobacco in any form?
29. Do you have a history of sickle-cell anemia in your family?
30. Have you had any other medical problems?
31. Have you had a medical problem or injury within the last year?
32. Can you swim?
33. When was your last tetanus shot?
Please explain any YES answers from questions 1-31:
Physician and Parental Permission
KHSAA Form GE04, Rev. 5/12, page 2 of 4
PART III - PHYSICAL EXAMINATION
This part must be completed by an authorized health care provider named in Bylaw 2.
PATIENT NAME: ____________________________________________
HEIGHT: ______ WEIGHT ______ BP _____ / ______ PULSE ______
VISION: R- 20/ ____ L- 20/ ____ BOTH- 20/ ____ CORRECTED? Y N
Normal
Abnormal
Comment
HEART
Rhythm (Regular/Irregular)
Murmur (supine)
Murmur (standing)
ENT
Lungs
Skin
Abdominal
Genitalia
Musculoskeletal
Neck
Shoulder
Elbow
Wrist
Hand
Back
Knee
Ankle
Foot
Dental
Other
After having reviewed the data above and the student's medical history, I make the following recommendations on
participation in athletics:
1. Cleared ______________________________________________________________________________________
2. Cleared after additional evaluation for _______________________________________________________________
3. Restricted from participating in the sports of __________________________________________________________
4. Cleared only to participate in the sports of ___________________________________________________________
Recommendations/Restriction (attach additional if necessary) ______________________________________________
_______________________________________________________________________________________________
In accordance with KHSAA Bylaws, I have examined the physical condition of the student and find the said student to
be physically fit to practice for and participate in interscholastic athletic contests.
Provider’s Name (please print)
Authorized Signature
Address:
City/State/Zip
Date:
Phone
This Physical Examination is valid for one year from date administered should be kept in a secure location
until the student has exhausted eligibility, graduated from high school and reached the age of 19.
Physician and Parental Permission
KHSAA Form GE04, Rev. 5/12, page 3 of 4
PART IV – CONSENT INFORMATION 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 and sign where required. 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 19.
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 at http://www.khsaa.org/handbook/. 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.
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
performance based statistics) 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 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, 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 acknowledge that they are aware
of and will review if desired, the education materials available through the KHSAA, the Centers for Disease Control and
other agencies regarding education all individuals with respect to nature and risk of concussion and head injury, including
the continuance of play after concussion or head injury.
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.
Physician and Parental Permission
KHSAA Form GE04, Rev. 5/12, page 4 of 4
PART V - STUDENT AND PARENT/GUARDIAN ACKNOWLEDGMENT OF RISK, ELIGIBILITY RULES, LIABILITY
WAIVER AND CONSENT AND RELEASE AND EMERGENCY PERMISSION FORM
This part must be completed by student and custodial parent / guardian). This form must be reproduced in order for a
copy to travel with respective athlete.
STUDENT AND PARENT/GUARDIAN ACKNOWLEDGMENT OF RISK, ACKNOWLEDGEMENT OF ELIGIBILITY
RULES, LIABILITY WAIVER AND CONSENT AND RELEASE
Students’ Name (please print)
School
Student and Parent/Guardian Address including City, State and Zip
Signature of Student
Date
Please list above any health problems/concerns this student may have, including allergies (medications / others) and any
medications presently being used
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
REQUIRED INSURANCE INFORMATION (KHSAA Bylaw 2)
Insurance Carrier
Policy Number
EMERGENCY CONTACT INFORMATION
Name (please print)
Relation to Student
Emergency Contact Address, including City, State and Zip
Daytime 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 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
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 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 19.
JEFFERSON COUNTY PUBLIC SCHOOLS
ADDENDUM TO KHSAA PHYSICAL FORM
This addendum to the physical form must be completely filled out and reviewed by the medical professional administering the physical exam along with all other information. List any prescription medications that you are currently taking: If none, parent please initial: _______ List any over‐the counter medications, pills, or supplements that you are currently taking: If none, parent please initial: _______ _________________________________________ ________________________________________ (Parent printed name) (Parent Signature) _________________________________________ ________________________________________ (Student printed name) (Student Signature) _________________________________________ _________________________________________ (Physician Printed Name) (Physician Signature) _________________________________________ (Date) Jefferson County Public Schools Could it be a concussion?
When in doubt, take the player out.
Observe the athlete for
these warning signs
Does the athlete report
any of these symptoms
Appears dazed or stunned
Headache
Is confused about assignment
Neck pain
Forgets plays
Balance problems or dizziness
Is unsure of game, score or
opponent
Double or fuzzy vision
Moves clumsily
Nausea or vomiting
Answers questions slowly
Hearing problems or ringing
Loses consciousness
Confusion
Shows behavior or personality
changes
Drowsiness
Can’t recall events prior to or
after hit
Feeling sluggish
Unequal size pupils
Concentration or memory
problems
Continued on reverse
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Knowing the signs of concussion can prevent further injury
or even death.
The facts:
Seek medical attention
• A concussion is a brain injury.
• All concussions are serious.
• Concussions can occur without loss of consciousness.
• Concussions can occur in any sport.
• Second impact syndrome, a rare
condition in which a second
concussion occurs before a first
concussion has healed, causes rapid
and severe brain swelling and often
permanent damage.
• Ensure the athlete is evaluated by an
appropriate health care professional.
Do not try to judge the severity of
the injury yourself.
If the athlete exhibits or reports
any warning signs of concussion,
follow these steps:
• Second impact syndrome can be
prevented by delaying the athlete’s
return to play until the athlete
receives appropriate medical
evaluation and approval to play.
Remove from play
Inform parent/guardian
• Make sure the athlete’s parents or
guardians are informed about the
injury and that the athlete should be
seen by a health care professional.
Prevent further injury
• Only allow the athlete to return
to play with permission from an
appropriate health care professional.
If you suspect an athlete has a concussion, the Headache &
Concussion Center is here to help. As the only center of its
kind in the area, our physicians have extensive training and
specialized diagnostic tools to properly treat concussions.
For more information, call the center at (502) 899-6782 or
visit NortonHealthcare.com/HeadacheandConcussion.
© Norton Healthcare 12/10 ORT-4307
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Parent/Guardian Student-Athlete Concussion Statement
▉ I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer
and/or team physician.
▉ I have read and understand the Norton Sports Health Concussion Fact Sheet.After reading the
concussion fact sheet, I am aware of the following information:
Initial Each Line
________ A concussion is a brain injury, which I am responsible for reporting to my team physician or athletic
trainer.
________ A concussion can affect my ability to perform everyday activities, and affect reaction time, balance,
sleep, and classroom 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 concussion, I am responsible for reporting the injury to my team
physician or athletic trainer.
________ I will 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.
________ Following aconcussion, the brain needs time to heal. You are much more likely to have a repeat
concussion if you return to play before your symptoms resolve.
________In rare cases, repeat concussions can cause permanent brain damage, and even death.
__________________________________
Signature of Student-Athlete
________________
Date
__________________________________
Printed name of Student-Athlete
__________________________________
Signature of Parent/Guardian
__________________________________
Printed name of Parent/Guardian
________________
Date
JEFFERSON COUNTY PUBLIC SCHOOLS
(Last Name)
(First Name)
GENDER:
M
(Middle)
F
(circle one)
(Birth date)
NUMBER OF YEARS IN: MIDDLE SCHOOL
HIGH SCHOOL
YEAR ENTERED 9
NUMBER OF YEARS PLAYED VARSITY SPORTS COUNTING THIS YEAR:
(Home Address)
GRADE:
.
(Zip)
PARENT/GUARDIAN:
WORK PHONE#:
EMERGENCY CONTACT:
PHONE#:
PHYSICAL EXAM COMPLETED: YES
GROUP ATHLETIC INSURANCE PAID: YES
TH
(Home Phone #)
NO
NO
LAST SCHOOL ATTENDED:
YEAR (S):
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
PARENT PERMISSION/RELEASE – HIGH SCHOOL ATHLETICS
I acknowledge receipt of a copy of the K.H.S.A.A. Eligibility Rules and Regulations and am familiar with these
requirements.
I understand the personal safety of the student is of first importance to the school. In the event of needed
professional medical care, I give my permission for a representative of the school to transport my child to the
nearest medical facility and for staff of that facility to render treatment.
***PREFERRED HOSPITAL
I agree to be responsible for equipment issued by the school and to return same property upon request by the
school.
I consent for my child to participate in athletics during this school year and understand the school will pay NO
medical or drug bills for accidents incurred in this activity/sport.
I have medical and hospital insurance with:
The certificate number is:
I understand there is NO waiver for the Group Athletic Insurance Program for all participation athletes. I have paid the
$5.00 tryout premium and agree to pay the additional $15.00 premium in the event my child becomes a member of any
respective athletic team. This insurance is a secondary policy with coverage limitations and benefits are payable for
“Reasonable and Customary” expenses with a benefit maximum of $25,000. The K.H.S.A.A. carries a catastrophic policy
on all athletics that provides coverage in excess of $25,000.
This Permission/Release form MUST BE SIGNED, NOTARIZED AND RETURNED to the Athletic Department before the
student will be permitted to participate.
(Student’s Signature)
This form notarized the
My commission expires on the
(Parent’s Signature)
day of
day of
20
.Notary Public
20
.
Student Name: __________________
School: ________________________
Sports: ________________________
JEFFERSON COUNTY PUBLIC SCHOOLS
SPORTS SAFETY VIDEO FORM
Combination 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)
____________________________
School
____________________________
Grade
____________________________
Date
____________________________
Parent Signature
____________________________
Student Signature
Louisville duPont Manual High School
David Zuberer
Athletic Director
120 West Lee Street
Louisville, KY 40208
Athletic Office: (502) 485-8489
School Office: (502) 485-8241
School Fax: (502) 485-8035
WAIVER FOR DISMISSAL OF TRANSPORT FROM SITE OF ACTIVITY
I consent for my child,
to be dismissed from required transport between the site of an activity within Jefferson County
and duPont Manual High School.
I hereby waive and release any and all rights and claims for damage I may have against
duPont Manual High School for releasing my child from required transport back to duPont
Manual High School from within Jefferson County.
WAIVER OF RESPONSIBILITY FOR PARTICIPANT BEING TRANSPORTED
I consent for my child,
to be transported by private vehicle when needed, driven by an adult and approved by the
principal, to all athletic/activity events in which my child is participating. I hereby waive and
release any and all rights and claims for damage I may have against duPont Manual High School
and the driver of the private vehicle.
SIGNATURE OF PARENT OR GUARDIAN
DATE
THIS FORM NOTARIZD THE ________ DAY OF _______________, 20________.
NOTARY PUBLIC _______________________________________________________.
MY COMMISSION EXPIRES ON THE ________ DAY OF _______________, 20 ________.
Louisville duPont Manual High School
David Zuberer
Athletic Director
120 West Lee Street
Louisville, KY 40208
TO:
FR:
RE:
Athletic Office: (502) 485-8489
School Office: (502) 485-8241
School Fax: (502) 485-8035
Manual Athletes and Parents
David Zuberer, Athletic Director
Parental Communication Agreement
I would like to welcome you to the upcoming Manual athletic season. The coaching staff and I are
delighted to be working with such fine young people. We have great expectations for them both as players
and student-athletes. Over the course of this year, situations may arise that need to be addressed by the
coaching staff, player, and/or parent(s) according to a definite procedure. This document explains the
procedure that will be used to address these situations.
Because emotions are high directly after a game or related event, it is important to avoid any potentially
volatile situations between parents and the coaching staff. Often a cooling off period allows all parties to
gain perspective on the situation. Our athletic department 24-hour policy is not to discuss with parents
game results or decisions within 24 hours of the event. If a parent needs to voice a concern, the parent
should schedule a meeting with the head coach that will occur after 24 hours have passed. If a parent
cannot wait and must voice their issue prior to the passage of 24 hours, then his/her son/daughter will be
given an automatic one-game suspension.
The anticipated situations are playing time, role on the team, and development. These are situations that
must be handled between the player and the coaching staff. Although we appreciate your interest and
support of the Manual athletic program, the coach must make the decisions in these areas. In order for
proper communication, the following procedures must be followed to address any of the noted situations or
other problems that may arise.
STEP 1:
The player and coaching staff member will have a meeting to address and discuss the player’s
questions or concerns. The player must request the meeting, preferably before the beginning of
a practice session. The staff will respond to the athlete’s inquiries and concerns. Most
situations should be resolved at this stage.
STEP 2:
If the athlete continues to have questions concerning the situation addressed in Step 1, the
player must request a Step 2 meeting. The player and a coaching staff member will meet
again. At this meeting, they will discuss the problem, questions, and previous issues to assess
if further action is necessary. The coach will determine if parental participation at this meeting
would be productive.
STEP 3:
If the athlete remains dissatisfied with the coaching staff’s response after Steps 1 & 2, the
player will need to request a Step 3 meeting via the head coach. The player, parent, coach, and
athletic director will meet at an agreeable time. The coaching staff and athletic director will
address and respond to the inquiries as soon as possible.
All parents and players must sign this document agreeing to the above procedures. Hopefully, by adopting
and implementing this procedure, it will help to promote a clear and fair resolution to issues of concern.
Player Name (please print):
Player’s signature:
Date:
Parent’s signature:
Date:
duPont Manual High School
120 West Lee Street, Louisville, KY 40208
(502) 485-8241
STUDENT-ATHLETE SOCIAL MEDIA POLICY
Manual High School student-athletes are representatives of their family, their team, their high
school, and their community. With that in mind, our student-athletes are expected to exercise good
judgment in their use of social media, conducting themselves in a responsible and respectful
manner.




It is impermissible for student-athletes to post information, photos, or other
representations of sexual content, inappropriate behavior (e.g., drug or alcohol use), or
items that could be interpreted as demeaning or inflammatory.
Student-athletes are required to abide by all team policies, school policies, and KHSAA rules
when utilizing social media.
It is not permissible to comment on injuries, officiating, coaching decisions or team matters
that could reasonably be expected to be confidential to team members.
Student-athletes are required to follow all respective social media rules.
Best Practices and Reminders




Think twice before posting. If you wouldn't want your coach, parents, or future employer to
see your post, don't post it.
Be respectful and positive.
Remember, many different audiences view your posts including fans, children, local
authorities, parents, faculty, etc.
The internet is permanent. Even if you delete something, it's still out there somewhere.
Coaches and administrators monitor social media websites. Potential employers use these
social media websites to screen candidates. Use the privacy/security settings made available
on these sites.
Violation of the Student-Athlete Social Media Policy may result in disciplinary action-- including
temporary or permanent suspension from the team--as determined by administration and head
coach. By signing below, the athlete and parent agree to abide by these rules.
______________________________
Athlete Signature
______________________________
Parent Signature
______________________________
Date
______________________________
Date
Jefferson County Public Schools
Photo/Videotape 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, audiotape/videotape students, or interview students for school-related stories in a way that would
individually identify a specific student. Those photographs and/or audio/videotaped images or interviews
may appear in district publications; in district video productions; on the district web site; in the news media;
or in other nonprofit, education-related organizations’ publications. Please complete this form, and return it
to your child’s school.
❑ I hereby grant unto the Jefferson County Public Schools (JCPS) permission to use my child’s,
photograph and/or videotaped image for the purposes mentioned above. I understand and agree
that JCPS may use these photos and/or videotaped images in subsequent school years unless I
revoke this authorization by notifying the school principal in writing. I further grant unto JCPS
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’s/Guardian’s Name: ________________________________________________________________
Address: ______________________________________________________________________________
City/State: _____________________________________________________ Zip Code: ______________
Telephone Number: ______________________________________________________________________
Parent’s/Guardian’s Signature*: _________________________________________ Date: _____________
* Students 18 years of age or older may sign this release form for themselves.
Equal Opportunity/Affirmative Action Employer Offering Equal Educational Opportunities
080107
54
Jefferson County Public Schools