pisd_athletic_forms

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Apr 3, 2024

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Palmer Athletics Parent Information Form School Year: Athletes Name: Athletes Phone #: Parents Name: Parents Phone #: Email: Address:
Ravised July 2008 THE UNIVERSITY OF TEXAS AT AUSTIN UNIVERSITY INTERSCHOLASTIC LEAGUE PHOTOGRAPHIC CONSENT AND RELEASE FORM I hereby authorize the University of Texas at Austin and the University Interscholastic League (University), and those acting in pursuant to its authority to: (a) Record my likeness and voice on a video, andio, photographic, digital, electronic or any.other medium. (b) Use my name in connection with these recordings. {c) Use, reproduce, exhibit or distribute in any medium (e.g. print publications, video tapes, CD-ROM, Internet/WWW) these recordings for any purpose that the University, and those acting pursuant to its authority, deem appropriate, including promotional or advertising efforts. I release the University and those acting pursuant to its authority from liability for any violation of any personal or proprietary right I may bave in connection with such use. I understand that all such recotdings, in whatever medium, shall remain the property of the University. I have read and fully understand the terms of this release. Name: Address: Street City State ZIP Phone: Signature: | Date: Parent/Guardian Signature (if under 18): Date:
CARDIAC ARREST (SCA) AWARENESS FORM The Basic Facts on Sudden Cardiac Arrest Website Resources: American Heart Association: www.heart.org Lead Author: Arnold Fenrich, MD and Benjamin Levine, MD Additional Reviewers: UIL Medical Advisory Committee Revised 2016 » QOccurs suddenly and often without warning. > An electrical malfunction (short- circuit) causes the bottom chambers of the heart (ventricles) to beat dangerously fast (ventricular tachycardia or fibrillation) and disrupts the pumping ability of'the heart. » The heart cannot pump blood ta the brain, lungs and other organs of the body. » The person loses consciousness (passes out) and has no pulse. $ Death cccurs within minutes if not treated immediately. heart muscle: Hypertrophic Cardiomyopathy - nypertrophy (thickening) of the left ventricle; the most commorn cause of sudden cardiac arrest in athletes in the U.S. ; Arrhythmogenic Right Ventricular Cardiomyopathy - replacement of part of the right ventricle by fat and scar; the most common cause of sudden cardiac arrestin Italy. Marfan Syndrome - a disorder of the structure of blood vessels that makes ‘them prone to rupture; often associated with very long arms and unusually flexible joints. Inherited conditions present at birth of the electrical system: Long QT Syndrome ~ abnormality in the jon channels (electrical system) of the heart. Catecholaminergic Polymorphic Ventricular Tachycardia and Brugada Syndrome - other types of electrical abriormalities that are rare but run in families. NonInherited (not passed on from the family, but still presentat birth) conditions: Coronary Artery Abnormalities - abnormality of the blood vessels that supply blood to the heart muscle. This is the second most comimon cause of sudden cardiac arrest in athletes in the U.S. Aortic valve abnormalities - failure of the aortic valve {the valve between the heart and the aorta) to develop properly; usually causes a loud heart UL Non-compaction Cardiomyopathy - a condition where the heart muscle does not develop normally. "> Fainting/blackouts (especially Siidde during exercise) > Dizziness » Unusual fatigue/weakness » Chestpain » Shortness of breath » Nausea/vomiting » Palpitations (heart is beating unusually fast.or skipping beats) » Pamily history of sudden cardiac arrestatage < 50 ANY of these symptoms and warning signs that oceur while exercising may necessitate further evaluation from your physician before returning to practice or @ game. Idiopathic: Sometimes the underlying T1m is cr cl' Wolff-Parkinson-White Syndrome - response is vital an extra conducting fiber is presentin » CALL 911 the heart's electrical system and can > Begin CPR increase the risk of arrhythmias. » Use an Automated External Conditions not present at birth but Defibrillator (ARD) acquired later in life: Thatara e taiscre Commotio Cordis - concussion of the : heart that can occur from being hitin the chest by a ball, puck, or fist. The American Heart Association recommends a pre-participation history and physical including 14 impoertant cardiac elements, The UIL Pre-Participation Physical Evaluation - Medical History form includes ALL 14 of these important cardiac elements and is mandatory annually. Myocarditis - infection or inflammation of the heart, usually caused by a virus. Recreational/Performance- Enhancing drug use. cause of the Sudden Cardiac Arrestis unknown, even after autopsy.
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requires use of the specific Preparticipation Medical History form on a yearly basis. This process begins with the parents and. student-athletes answering questions about symptoms during exercise (such as chest pain, dizziness, fainting; palpitations or shortness of breath); and guestions about family health history. Itis important to know if any family member died suddenly during physical actvity or during a seizure. Itis also {mportantto know if anyone in the family under the age of 50 had an unexplained sudden death suchas drowning or car accidents. This information must be provided annually Additio g using an electrocardiogram (ECG) and/or an echocardiogram (Echo) is readily available to all athletes from their personal physicians, but is not mandatory, and is generally not recommended by either the American Heart Association (AHA) or the American College of Cardiology (ACC). Limitations of additional scteening include the possibility (~10%) of “false positives”, which leads to unnecessary stress for the student and parent or guardian as well as unnecessary restriction from athletic participation. There is also a possibility of “false negatives”, since not all cardiac conditions will be identified by additional screening. because it is essential to identify those at g risk for sudden cardiac death. The University Interscholastic League requires the Preparticipation Physical Examination form prior to junior high athletic participation and again prior to the 15tand 3 years of high school participation. The required physical exam includes measurement of blood pressure ard a careful listening examination of the heart, especially for murmurs and rhythm abnormalites. If there are no warning signs reported on the health history and no abnormalities discovered on exam, no additional evaluation or testing is recommended for cardiac issues/concerns. If a qualified examiner has concerns, a referral to a child heart spectalist, a pediatric cardiclogist, is recommended. This specialist may perform a more thorough evaluation, includingan - electrocardiogram (ECG), whichisa graph of the electrical activity of the- heart. An echocardiogram, which is an ultrasound test to allow for direct visualization of the heart structure, may also be done. The specialist may also order a treadmill exercise test and/or a monitor-to enable a longer recording of the heart rhythm. None of the testing is invasive or uncomfortable. | SR by I prev i The only effective treatment for A prope ' Physical Evaluation - Medical History) should find many, but not all, conditions that could cause sudden death in the athlete, This is because some diseases are difficult to uncover and may only develop later in life, Others can develop following a normal screening evaluation, such as an infection of the heart muscle | from a virus. This is why a medical history and a review of the family health history need to be performed on a yearly basis. With proper screening and evaluation, most cases can be identified and prevented. yent ventricilar fibrillation is immediate use of an automated external defibrillator 8 (AED). An AED can restore the heart back into a normal rhythm. An AED is also life-saving for ventricular fbrillation caused by a blow to the chest over the heart (commotio cordis). Texas Senate Bill 7 requires that at any school sponsored athletic event or team practice in Texas public high schools the following must be available: > An AED isin an unlocked location on school property within a reasonable proximity to the athletic field or gymmnasiom All coaches, athletic trainers, PE teacher, nurses, band directors and cheerleader sponsors are certified in cardiopulmonary resuscitation (CPBR) and the use of the AED. x> Parent/Guardiah Name {Print) Fach school has a developed safety procedure to respond to a medical emergency involving a cardiac arrest. The American Academy of Pediatrics recommends the AED should be placed in a central location that is accessible and ideally no morethana1to 11 /2 minute walk from any location and that a call is made to activate 911 emergency system while the AED is being retrieved. FArg EXCALAAL K R 1 certify that I have read and understand the above information. q Parent/Guardian Signature Date Student Signature .Student Name (Print) Date
CONCUSSION QGKNOWLEDGEMENT FORM Nurne of Student Definition of Concussion - means a complex pathophysiological process affecting the brain caused by a traumatic physical force or impact to the head or body, which may: (A) inchide temporary or prolonged altered brain function resulting in physical, cognitive, or emotional symptoms or altered sleep patterns; and (B) involve loss of consciousness. Prevention ~ Teach and practice safe play & proper technigue. - Follow the rules of play. - Make sure the required protective equipment is worn for all practices and games. ~ Protective equipment must fit properly and be inspected on a regular basis. Signs and Sympioms of Concussion — The signs and symptoms of concussion may include but are not limited to: Headache, appears to be dazed or stunned, tinnitus (ringing in the ears}, fatigue, shurred speech, nausea or yomiting, dizziness, loss of balance, blurry vi- sion, sensitive to light or noise, feel foggy or groggy, memory loss, or confusion. Oversight - Bach district shall appoint and approve a Concussion Oversight Team (COT). The COT shall include at least one physician and an athletic trainer if one is emplayed by the school district. Other members may include: Advanced Practice Nurse, neuropsy- chologist or a physician’s assistant. The COT is charged with developing the Return to Play protocol based on peer reviewed scientific evidence. Treatment of Concussion - The student-athlete/cheerleader shall be removed from practice or participation immediately if suspected to have sustained a concassion. Every student-athlete/cheerleader suspected of sustaining a concussion shall be seen by a physician before they may- return to athletic or cheerleading participation, The treatment for concussion is cognitive rest. Students should limit external stimulation such as watching television, playing video games, sending text messages, use of compnter, and bright lights. When all signs and symptoms of concussion have cleared and the student has received written clearance from a physician, the student-athlete/cheerleader may begin their district’s Return to Play protacol as determined by the Concussion Oversight Team. Return to Play - According to the Texas Education Code, Section 38.157: A student removed from an interscholastic athletics practice or competition (including per UIL rule, cheerleading) under Section 38.156 may not be permitted to practice or participate again following the force or impact believed to have caused the concussion until (1) the student has been gvaluated, using established medical protocols based on peer-reviewed scientific evidence, by 2 treating physician chosen by the student or the student s parent or guardian or another person with legal authority to make medical decisions for the student; (2) the student has successfully completed each requirement of the return-to-play protoco! established under Section 38.153 necessary for the student to return to play; (3) the treating physician has provided a written statement indicating that, in the physician s professional judgment, it is safe for the stident to return to play; and (4) the student and the student ’s parent or guardian or another person with legal authority to make medical decisions for the student: (A) have acknowledged that the student has completed the requirements of the return-to-play protocol necessary for the student to return to play; (B) have provided the treating physician s written statement under Subdivision (3) to the person responsible for compliance with the return-to-play protocol under Subsection {c) and the person who has supervisory responsibilities under Subsection {c); and (C) have signed a consent form indicating that the person signing; (i) has been informed concerning and consents to the student participating in returning to play in accordance with the return-to- play protocol (it) understands the risks associated with the student returning to play and will comply with any ongoing requirements in the retura-to-play protocel; - (1ii) consents to the disclosure to appropriate persons, consistent with the Health Insurance Portability and Accountability Act of 1996 (Pub. L. No. 104-181), of the treating physician s written stafement under Subdivision (3) and, if: angt, the return-to-play recommenda- tions of the treating physician; and (iv) understands the immunity provisions under Section 38.159. Parent or Guardian Signature Date Student Signatuse ' Date
University Interscholastic League Parent and Student Agreement/Acknowledgement Form Anaholic Steroid Use and Random Steroid Testing Texas state law prohibits possessing, dispensing, delivering or administéring a sterold in a manner not allowed by state law. Texas state law also provides that body building, muscle enhancement or the increase in muscle bulk or strength through the use of a steroid by a person who Is in good health is not a valid medical purpose, Texas state law requires that only a ficensed practitioner with prescriptive authority may prescribe a steroid for a person. Any violation of state law concerning steroids is a criminal offense punishable by confinement in jail or imprisonment in the Texas Depariment of Criminal Justice. STUDENT ACKNOWLEDGEMENT AND AGREEMENT As a prerequisite to participation in UIL athletic activities, | agree that | will not use anabdlic steroids as defined in the UIL Anabolic Steroid Testing Program Protocol. | have read this form and understand that | may be asked to submit to testing for the presence of anabolic steroids in my body, and 1 do hereby agree to submit to such testing and analysis by a certified laboratory. 1 further understand and agree that the results of the steroid testing may be provided to certain individuals in my high school as specified in the UL Anabolic Steroid Testing Program Protocol which is available on the UL website at www. uiltexas.org. | understand and agree that the resuits of steroid festing will be held confidential to the extent required by law. | understand that failure to provide accurate and truthful information could subject me to penalties as determined by UIL. Student Name (Print): Grade (9-12) Student Sighature: Date: PARENT/GUARDIAN CERTIFICATION AND ACKNOWLEDGEMENT As a prerequisite to participation by my student in UIL athlstic activities, 1 certify and acknowledge that | have read this form and understand that my student must refrain from anabolic steroid use and may be asked fo submit to testing for the presence of anabolic steroids in hisfher body. | do hereby agree to submit my child to such testing and analysis by a certified laboratory. 1 further understand and agree that the results of the steroid testing may be provided to certain individuals in my student's high school as specified in the UIL Anabolic Steroid Testing Program Protocol which is available on the UIL website at www. Uiltexas.org. | understand and agree that the results of steroid testing will be held confidential to the extent required by law. | understand that failure to provide accurate and truthful information could subject my student to penalties as determined by UlL, Name (Print). Signature: Date: Relationship to student: School Year (to be completed annually)
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PREPARTICIPATION PHYSICAL EVALUATION -- MEDICAL HISTGRY 2020 This MEDICAL HISTORY FORM must be completed ansusily by parent {or guardian) and student in order for the student to participate in sctivities, These “ guestipns are desigoed fo determing if the student has developed any condition which would make it hazardous fo patticipate in an event. ixplain “ Yes" answers in the box below™*, Circle questions you dor’t know the answers to. L Pt wa h 5 6. % 8 9 Student's Name: (print} Sex Age Date of Birth Address Phone - Grade Schoot ' Personal Physician Phong In cose of emergency, contact; Name Relationship _Phone (H) v (W), Have you had a medical illness or injury sinee your last check up or physical? - Have you been hospitalized overnight in the past year? Have you ever had surgery? Have you ever had prior testing for the heart ordered by a physician? Have youever passed out during or after exercise? Have you ever had chest pain during or after exerciss? Do you get tived more quickly than ytmr friends do during exercise? Have you ever had racing of your heart or skipped heartbeats? Have you had high blood pressure or high cholesterol? Have you ever been-told you have 3 heart murmur? Has any family wember or relative died of heart problems or of sudden unexplained death before age 507 Hag any family member been disgnosed with enlarged heart, (dilated cardiomyopathy), hypertraphic cardiomyopathy, long QT syndroms or other ion channelpathy (Brugada syndrome, etc), Marfan's syndrome, or abnormal heart thythm? Haye you had & gevere viral infection (for example, myocarditis or mononucleosis) within the Jast month? Hag a physician ever denied or restricted your participstion in activities for any heart problems? Have you ever had a head injury or concussion? Have you ever been knocked out, become unconscious, or Jost your memory? If yes, how many times? When was your last concussion? How severe was each one? (Explain below} Have you ever had a seizure? Da you have frequent or severs headaches? Have you ever had numbness or tingling in your amns, hands, legs or feet? Have you ever had a stinger, burnier, or pinched nerve? Axe you missing any paired organs? Are you under a doctor’s care? Are you cnrrently faking any prescription or non-preseription (over-the-counter) medication or pills or using an inhaler? Do you have any allergies (for example, to polien, medicine, food, or stinging insects)? Have you ever been dizzy during or afler exercise? 10. Do you have any current skin problems (for example, itching, il 12, rashes, acne, warts, fungus, or bhstem)" Have you ever become il from exercising in the heat? Have you had any problems with your eyes or vision? ¥es Mo 0 oA0o OO0 Ooo o O Oooo Ooo ooo O oo o0 O oooo ooo OO OO O OO0 ood o OO oo, O O 13. Have you ever gotten unexpectedly short of breath with exercise? Do you have asthma? Do you have seasonal allergies that require medical treatment? 14, Doyouuseany special protective or corrective equipmentor devices that aren't usually used for your activity or position {for example, knes brace, speeial neck roll, foot orthotics, retainer on your testh, hearing aid)? 15, Have you ever had a sprain, strain, or swelling afier injury? Have you broken or fractured any bones or dislocated any joints? Have you hed any other problems with pain or swelling in muscles, tendons, bones, or joints? If yes, check appropriate box and explain below: oo o arl O O [] Heed [ Elbow 1 =ip 1 Neck [ Forearm 7 Thigh 1 Back ] wrist [ Xnee [1 Chest El Haod [] shin/Calf B Shoulder ] Finger 1 Ankle Upper Atm [ Foot 16, Do you want to weigh more or less than you do now? O 1% Do you feel stressed out? 1 18. Have you sver been diagnosed with or treated for sickle cefl i trait or sickle cell dizease? Females Only 19, When was your first menstrual period? ‘When wag your most recent menstrual period? How much tine do you usnally have from the start of one period fo the start of another? How many periods have you had in the last year? ‘What was the longest time between periods in the lagt year? Males Only 20. Are you missing a testicle? 21. Do you have any testicular swelling or masses? _ oo og mlm i DAn electrocardiogram (ECG) is not required. T have read and understand the information about cardiac screening on the UIL Sudden Cardiac Arrest Awareness Form, By checking this box, X choose to obtain an BCG for my student for additional cardiac screening, T understand it is the responsibility of my family to schedule and pay for such ECG. EXPLAIN *YES” ANSWERS IN THE BOX BELOW (attach another sheet if necessary): It is understood that even fhough protective equipment is wom by athletes, whenever nesded, the possibility of an accident still remains. Neither the University Interscholastic League nor the school assumes any respensibility in case an accident occus, If, in the judgroent of any representative of the schwl, the sbove student should need immediate care and treatment o8 a result of any njury or sickness, 1 do hercby request, anthorize, and consent to such care and teatment ss may be given said student by any physician, athletic hralner, nucse or school representative. I do hereby agree to indempify and save hanmless the school and any school or hospital representative from any claim by any person on account of such care and treatment of said stodent. If; between this date and the beginaing nf participation, auy iliness or injury should ccour that ray lirit this student's participation, I agree to notify the schoot anfimntms of such illness or injury. Student Sigdature: Parent/Guardian Signature: { hereby state thaf, to the-best of my knowledge, my answers fo the above questions ave complete and correct. Failure to provide truthful responses could subject the student in question to penaliies determined by the UIL Date: Any Yes answer to questions 1, 2, 3, 4, 5, or 6 requives farther medical evaluation which may include s physical examination. Written clearance from a physician, physician assistant, chivopractor, or nurse practifioner is required before any participation fn UIL practices, games or matches, THIS FORM MUST BE ON FILE FRIOR TG PARTICIPATION IN ANY PRACTICE, SCRIMMAGE, PERFORMANCE OR CONTEST BEFO‘RE; DURING OR AFTER SCHOOL. For School Use Ouly: This Medical History Porm was reviewed by: Printed Name Date Signature
PREPARTICIPATION PHYSICAL EVALUATION — PHYSICAL EXAMINATION Student's Name Sex Age Date of Birth, Height Weight % Body fat (optional) Pulse BP / {( 1 / ) brachial blood pressure while sitting Vision: R 20/ L20/ Comrected: []Y [IN Pupils: [] Equal [ Unequal As a minimum requirement, this Physical Examination Form must be completed prior to junmior high participation and again prior to first and third years of high school participation. It must be completed if there are yes answers to specific questions on the student's MEDICAL HISTORY FORM on the reverse side. * Local district policy may require an annual physical exam. NORMAL ABNORMAL FINDINGS INITIALS* MEDICAL Appearance Eyes/Ears/Nose/Throat -Lymph Nodes Heart-Auscultation of the heart in the supine position. Heart-Auscultation of the heart in the standing position. Heart-Lower extremity pulses Pulses Lungs Abdomen Genitalia (males only) if indicated Skin Marfan's stigmata (arachnodactyly, pectus excavatum, joint hypermobility, scoliosis) Neck Back Shoulder/Arm ' Elbow/Forearm ‘Wrist/Hand Hip/Thigh Knee Leg/Ankle Foot *station-based examination only CLEARANCE [0 Cleared 0 Cleared after completing evaluation/rehabilitation for: [0 Not cleared for: Reason:' Recommendations: The following information must be filled in and signed by either a Physician, a Physician Assistant licensed by a State Board of Physician Assistant Examiners, a Registered Nurse recognized as an Advanced Practice Nurse by the Board of Nurse Examiners, or a Doctor of Chiropractic. Examination forms signed by any other health care practitioner, will not be accepted. Name (print/type) Date of Examination:’ Address: Phone Number: Signature: "Must be completed before a student participates in any practice, before, during or after school, (both in-season and out-of-season) or performance/
ACKNOWLEDGEMENT OF RULES Attention School Authorities: This form must be signed yearly by both the student and parent/guardian and be +|on file at your school before the student may participate in any practice session, scrimmage, or contest. A copy of the student’s medical history and physical examination form signed by a physician or medical history form signed by a parent must also be on file at your school. Student’s Name _ Date of Birth 1 Current School Parent or Guardian’s Permit 1 hereby give my consent for the above student to compete in University Interscholastic League approved sports, and travel with the coach or other representative of the school on any trips. Furthermore, as a condition of participation and for the purpose of ensuring compliance with University Interscholastic League (UIL) rules, I congent to the disclosure of personally identifiable information, including information that may be subject to the Family Bducational Rights and Privacy Act (FERPA), regarding the above named student between and among the following: the high school or middle school where the student currently attends or has attended; any school the student transfers to; the relevant District Executive Committes and the UIL. I further understand that all information relevant to the student’s UIL eligibility and compliance with other UIL rules may be discussed and considered in a public forum. I acknowledge that revocation of this consent must be in writing and delivered to the student’s school and the UIL. 1t is understood that even though protective equipment is worn by the athlete whenever needed, the possibility of an accident still remains, Neither the University Interscholastic League nor the high school assumes any responsibility in case an accident oceurs. I have read and understand the University Interscholastic League rules on the reverse side of this form and agree that my son/ danghter will abide by all of the University Interscholastic League rules. The undersigned agrees to be responsible for the safe return of all athletic equipment issued by the school to the above named student. If, in the judgement of any representatives of the school, the above student needs immediate care and treatment as a result of any injury or sickness, I do hereby request, anthorize, and consent to such care and treatment as may-be given to said student by any physician, licensed athletic trainer, nurse, hospital, or school representative; and I do hereby agree to indemuify and save harmless the school and any school representative from any claim by any person whomsoever on account of such care and treatment of said student. 1 have been provided the UIL Parent Information Manual regarding health and safety issues including concussions and my responsibilities as a parent/guardian. I understand that failure to provide accurate and truthful information on UIL forms could subject the student in question to penalties determined by the UIL. The UIL Parent Information Manual is located at www.uiltexas ..org/files/athlatics/manuals/pa.rent—infonnation—manual.pdf. Your signature below gives authorization that is necessary for the school district, its Heensed athlefic trainess, coaches, associated physicians andstudent insurance personnel to share information concerning medical diagnosis and treatment for your student. To the Parent: Check any activity in which this student is allowed to participate. D Bageball {] Football [1Softball D Tennis [] Basketball [ Golt ke Stiiamiani - [ITrack & Field L] Cross Country dembSwmsees W : [ Jvolleyball Date Signature of parent or guardian Street address City State _ Zip _ Home Phone . Business Phone S5 FRE
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Signature Page/Palmer Athletics #* All student athletes and parents must sign this form and return it before the student can participate in athletics. ** All forms below must be on file by the first day of practice. ___ Sudden Cardiac Arrest Awareness Form ___ Concussion Acknowledgement Form __ Anabolic Steroid Use and Random Testing Form __ UIL Acknowledgement of Rules Form ___ Photographic Consent and Release Form ; Medical History & Physical Forms (Medical history must be filled out " each year / Physical must be done for all students entering 7, 9 and 11% grades. All physicals are good for 2 years.') By signing this form you have read and understand the information and policies herein. The PISD Athletic Handbook can be found on our school website under Athletics. Student Signature Date: Parent Signature - Date: