Houston I.S.DANaltrip H.S.
Athletic Forms
Please Print
Equal Opportunity Policy: It is the policy of the Houston Independent School District not to discriminate on the basis
of age, color, handicap or disability, ancestry, national origin, marital status, race, religion, sex, veteran status, or
political affiliation in its educational or employment programs and actives.
Student Name:
Date of Birth:
Grade:
Address
Parent(syGuardian Name:
Home Phone:
Work Phone:
Parent Cell Phone:
***The following forms must be filled out and SIGNED before any student can
participate and or practice.
1)
2)
3)
4)
5)
Physical by Doctor
Parent Approval
UIL Steroid Testing Form
Insurance Form
Acknowledgement of Rules
6) HISD Media Release
7) Waltrip Rules
8) Concussion Form
9) Cardiac Form
10) Previous Participation Form
***An Insurance fee of $35 must be paid or a Waiver obtained.
- For a Waiver, parent must show proof of Health Insurance and an I.D.
- If a Waiver is obtained, PARENTS are responsible for all bills, if an injury occurs.
- The payment of $35 is HIGHLY RECOMMENDED!
***FOR OFFICE USE ONLY- DO NOT WRITE IN THIS BOX***
PHYSICAL
_PARENT APPROVAL
_STEROID TEST FORM
INSURANCE FORM
COACH'S SIGNATURE
ACKNOWLEDGE OF RULES
CONCUSSION FORM
HISD MEDIA RELEASE
CARDIAC FORM
WALTRIP RULES
PAID INSURANCE
PAPF
WAIVER
DATE
REVISED 6609
PREPARTICIPATION PHYSICAL EVALUATION -- MEDICAL HISTORY
This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) and student in order for the student to participate in athletic activities. These
questions are designed to determine if the student has developed any condition which would make it hazardous to participate in an athletic event.
Sex
Age
Date of Birth
Student's Name: (print)
Phone
Address
School
Grade
Phone
Personal Physician
In case of emergency, contact:
Phone (H)
Relationship
Name
(W)
Explain "Yes" answers in the box below**. Circle questions you don't know the answers to. Any Yes answer to questions 1,2,3,4,5, or 6 requires further
medical evaluation which may include a physical examination. Written clearance from a physician, physician assistant, chiropractor, or nurse practitioner is
required before any participation in UIL
practices, games or matches
Yes No
Yes No
Have you had a medical illness or injury since your last check
13. Have you ever gotten unexpectedly short of breath with
❑ ❑
up or sports physical?
exercise?
2. Have you been hospitalized overnight in the past year?
Do you have asthma?
❑ ❑
Have you ever had surgery?
Do you have seasonal allergies that require medical treatment?
3. Have you ever passed out during or after exercise?
14. Do you use any special protective or corrective equipment or
❑ ❑
devices that aren't usually used for your sport or position (for
Have you ever had chest pain during or after exercise?
example, knee brace, special neck roll, foot orthotics, retainer
Do you get tired more quickly than your friends do during
on your teeth, hearing aid)?
exercise?
15. Have you ever had a sprain, strain, or swelling after injury?
Have you ever had racing of your heart or skipped heartbeats?
Have you broken or fractured any bones or dislocated any
Have you had high blood pressure or high cholesterol?
joints?
Have you ever been told you have a heart murmur?
Have you had any other problems with pain or swelling in
Has any family member or relative died of heart problems or of
muscles, tendons, bones, or joints?
sudden unexpected death before age 50?
If yes, check appropriate box and explain below.
Has any family member been diagnosed with enlarged heart,
❑ ❑
(dilated cardiomyopathy), hypertrophic cardiomyopathy, long
❑ Head
❑ Elbow
❑ Hip
QT syndrome or other ion channelpathy (Brugada syndrome,
❑ Neck
❑ Forearm
❑ Thigh
etc), Marfan's syndrome, or abnormal heart rhythm?
❑
❑ Back
❑ Wrist
❑ Knee
Have you had a severe viral infection (for example,
13
❑ Chest
❑ Hand
❑ Shin/Calf
myocarditis or mononucleosis) within the last month?
❑ Ankle
❑ Shoulder
❑ Finger
Has a physician ever denied or restricted your participation in
❑ ❑
sports for any heart problems?
❑ Upper Arm
❑ Foot
4. Have you ever had a head injury or concussion?
O El
16. Do you want to weigh more or less than you do now?
❑❑
Have you ever been knocked out, become unconscious, or lost O 0
Do you lose weight regularly to meet weight requirements for
❑ ❑
your memory?
your sport?
•.
If yes, how many
When was the last
17. Do you feel stressed out?
times?
❑❑
concussion?
18. Have you ever been diagnosed with or treated for sickle cell trait ❑ ❑
How severe was each one? (Explain below)
or sickle cell disease'?
Have you ever had a seizure?
❑ ❑
Females Only
Do you have frequent or severe headaches?
❑ ❑
19. When was your first menstrual period?
Have you ever had numbness or tingling in your arms, hands,
❑
❑
When was your most recent menstrual period?
legs, or feet?
How much time do you usually have from the start of one
Have you ever had a stinger, burner, or pinched nerve?
❑
0
❑
❑
period to the start of another?
Are
you
missing
any
paired
organs?
5.
How many periods have you had in the last year?
6. Are you under a doctor's care?
❑ ❑
What was the longest time between periods in the last year?
7. Are you currently taking any prescription or non-prescription
❑ ❑
An individual answering in the affirmative to any question relating to a possible
(over-the-counter) medication or pills or using an inhaler?
cardiovascular health issue (question three above), as identified on the form, should be
8. Do you have any allergies (for example, to pollen, medicine,
restricted from further participation until the individual is examined and cleared by a
El ❑
physician, physician assistant, chiropractor, or nurse practitioner.
food, or stinging insects)?
9. Have you ever been dizzy during or after exercise?
❑
❑
**EXPLAIN 'YES' ANSWERS IN THE ROI BELOW
another Rivet if nezeRsarvl:
10. Do you have any current skin problems (for example, itching,
❑ ❑
rashes, acne, warts, fungus, or blisters)?
11. Have you ever become ill from exercising in the heat?
❑ ❑
12. Have you had any problems with your eyes or vision?
❑ ❑
It 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 school assumes any responsibility in case an accident occurs.
If, in the judgment of any representative of the school, the above student should need immediate care and treatment as a result of any injury or sickness, I do hereby
request, authorize, and consent to such care and treatment as may be given said student by any physician, athletic trainer, nurse or school representative. I do hereby
agree to indemnify and save harmless the school and any school or hospital representative from any claim by any person on account of such care and treatment of said
student.
If, between this date and the beginning of athletic competition, any illness or injury should occur that may limit this student's participation, I agree to notify the school
authorities of such illness or injury.
1.
❑
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Failure to provide truthful responses could
subject the student in question to penalties determined by the UIL
Student Signature:
Parent/Guardian Signature:
Date:
THIS FORM MUST BE ON FILE PRIOR TO PARTICIPATION IN ANY PRACTICE, SCRIMMAGE OR CONTEST BEFORE, DURING OR Al mil SCHOOL.
For School Use Only:
This Medical History Form was reviewed by: Printed Name
Data
Signature
❑
HOUSTON INDEPENDENT SCHOOL DISTRICT
ATHLETIC DEPARTMENT
7/03
PARENT'S APPROVAL FOR PARTICIPATION IN ATHLETICS AND EMERGENCY MEDICAL AUTHORIZATION
has my approval to play at home or away from
I hereby certify that
(Student)
home on the athletic teams of the
follows:
, as
Middle/High School, grade
(School)
BasebalVBasketball/Cheerleader/Cross-Country/Football/Golf/Soccer/Softball/Swimming/Tennisgrack/VolleybalVWrestling
(Parent will check sports or events he/she does not approve.)
I understand and agree that the HISD Board of Education and the employees and agents of HISD assume no responsibility or
liability for any accident or injury as a result of any aspect of participation in the sports listed above.
I understand and acknowledge that participation in the above-listed sports creates the potential for receiving an injury. With
the knowledge of this potential risk of injury, I am giving my son/daughter permission to participate in athletics and accept full
responsibility for this decision.
In the event of an injury, I hereby grant permission to school officials and employees to render, secure, and authorize
necessary medical treatment.
I understand that medical expenses for injuries will be paid only according to the HISD Department of Athletics rules, and
such payments do not waive HISD's general immunity or create any liability for injuries or damages.
My insurance company is
Policy Number
Group Number
(both parents, if possible)
Date
Telephone
Social Security Number
Home Address
Signed
(Parent or Guardian)
Date
Telephone
Social Security Number
(Parent or Guardian)
Home Address
Signed
(Parent or Guardian)
(Parent or Guardian)
I certify that this release was signed in my presence.
Student Social Security Number
Principal or Notary (no stamped signature)
(first year of participation requirement)
PLACE OF EMPLOYMENT (both parents, if possible)
(Father)
Name of Firm
(Mother)
Name of Firm
Address
Address
Phone
Phone
NOTE TO THE COACH: You must have a completed form before the student may participate in or practice for any sport.
File the original in the office of the school attended. You must file a copy every school year. A notarized copy or a copy
signed by the parents in the presence of the principal must be filed for the first year of participation at the school the student
attends. Thereafter, a parent approval signed by the parents or parent must be submitted before the student may participate.
Athletic Handbook
2003 — 2004
Section 6.0
6.3
Student Accident/Athletic Insurance
Available at the reduced cost of $35.00 per athlete, per school year!
If your child/children are covered on another medical plan, you then have the option to either purchase the
additional insurance, or waive HISD's Athletic Insurance fee by doing to following:
•
•
Be the parent or legal guardian of the athlete.
•
Show proof of medical insurance on your child/children.
Show a valid government or state-issued photo identification or driver's license.
Note: Since original signatures are required, Insurance waivers cannot be faxed.
ALL ATHLETES MUST BE INSURED TO PARTICIPATE IN ANY ATHLETIC ACTIVITY/
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.
Date of Birth
Student's Name
Current School
Parent or Guardian's Permit
I 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.
It 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 occurs.
I have read and understand the University Interscholastic League rules on the reverse side of this form and agree that my
son/daughter 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, authorize, 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 indemnify 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.
I 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 UII. Parent Information Manual is located at www.uiltexas.org/files/athletics/manuals/parent-information-manual.pdf.
Your signature below gives authorization that is necessary for the school district, its licensed athletic trainers, 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.
❑
❑
❑
❑
Baseball
Basketball
Cross Country
Wrestling
❑ Softball
Swimming & Diving
❑ Team Tennis
Football
❑ Golf
❑ Soccer
Date
Signature of parent or guardian
Street address
City
Home Phone
❑
State
Zip
Business Phone
❑ Tennis
❑Track & Field
❑ Volleyball
WALTRIP SENIOR HIGH SCHOOL
RULES AND REGULATIONS FOR VOLUNTARY ATHLETICS
BASEBALL, BASKETBALL, CROSS COUNTRY, FOOTBALL, GOLF, SOCCER,SOFTBALL, SWIM, TENNIS, TRACK, and VOLLEYBALL
Participation in athletics is a PRIVILEGE, not a RIGHT. Prior behavior, conduct, lack of participation and/or failure to maintain a
proper level of ATHLETICISM; could revoke/jeopardize/cancel your PRIVILEGE to participate in a sport at Waltrip.
Paperwork
•
•
•
Must have physical exam from a certified doctor each school year
Must turn in the following required paperwork: Physical Examination, Parent Approval Form, HISD Acknowledgement of Rules,
Anabolic Steroid Use and Random Steroid Testing Form, Concussion Acknowledgement Form, Sudden Cardiac Arrest
Awareness Form and Media Release Form.
Must pay $35.00 for athletics insurance or signed notarized waiver. *Waiver= Parent will be responsible for medical bills,
should an athlete receive an injury.
Attendance/ Discipline/ Attire
•
•
•
•
Be present and on time for all team meetings, practices, and games.
Obey directions and take constructive criticism/coaching from all coaches.
Proper grooming (Hair, dress, and overall appearance)
No earrings (BOYS) in the ATHLETICS AREA.
•
•
•
•
•
If an athlete fails to complete a full season, they may not participate in another sport until the conclusion if that season.
Sloppy dress, profanity, insubordination toward adults and/or disrespectful attitudes will not be tolerated.
Not allowed in the halls without permission/permits.
Maximize time in class DO NOT WASTE TIME; Minimize absences and tardiness
CONDUCT should be ABOVE normal conduct required of other students.
ELIGIBILITY
•
•
•
•
•
For UIL: Must receive 5 credits in the past year/have 10 credits after 2" d year/15 credits after the 3 rd year in high school.
Cannot be over the age of 18 on September 1 st of any given school year.
Can only participate four (4) consecutive years upon beginning the 9th grade.
Pass all courses during each six weeks grading period.
Student is allowed to practice with the team, if declared ineligible because of grades
SUSPENIONS FROM SCHOOL/INHOUSE SUSPENSIONS
•
•
•
•
•
Penalty to be ASSESSED depending on the SEVERITY of the OFFENSE.
Student cannot practice while on suspension (AT HOME or AT SCHOOL)
Student cannot play in the game the week of at home suspension.
Second (2nd) suspension (AT HOME) = Dismissal from all athletics that school year.
BREAKING TEAM RULES: Penalties to be set by: Head Coach of each sport.
TIME REQUIRED (PLAYING TIME) TO RECEIVE LETTER AWARD
HISD gives only "X" number of letters for per sport. Only "X" number of athletes can letter in each sport, unless the sport pays for the extra
letters.
•
Letters and jackets are earned by playing time, contribution to the team, desires, efforts and determination of the athlete.
•
Letter Awards and Jackets are LEFT TO THE DISCRETION OF THE HEAD COACH OF EACH SPORT.
WITHHOLDING OF LETTER AWARDS: If a student athlete demonstrates inappropriate conduct or behavior, HE/SHE will not be
permitted to wear the letterman jacket on school premises during HIS/HER remaining tenure at Waltrip High School.
Athlete's Signature:
Parent's/Guardian's Signature:
Parent's/Guardian's Signature:
Date:
SUDDEN CARDIAC ARREST AWARENESS FORM
Revised June 2013
Name of Student:
What is Sudden Cardiac Arrest?
➢ Occurs 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 to the brain, lungs and other organs of the body.
➢ The person loses consciousness (passes out) and has no pulse.
➢ Death occurs within minutes if not treated immediately.
What causes Sudden Cardiac Arrest?
➢ Conditions present at birth
■ Inherited (passed on from parents/relatives) conditions of the heart muscle:
♦ Hypertrophic Cardiomyopathy - hypertrophy (thickening) of the left ventricle; the
most common 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 arrest in 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 of the electrical system:
♦ Long QT Syndrome - abnormality in the ion channels (electrical system) of the heart.
♦ Catecholaminergic Polymorphic Ventricular Tachycardia and Brugada Syndrome
- other types of electrical abnormalities that are rare but run in families.
■ Nonlnherited (not passed on from the family, but still present at birth) conditions:
♦ Coronary Artery Abnormalities - abnormality of the blood vessels that supply blood
to the heart muscle. The second most common 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 murmur.
♦ Non - compaction Cardiomyopathy - a condition where the heart muscle does not
develop normally.
♦ Wolff- Parkinson - White Syndrome -an extra conducting fiber is present in the heart's
electrical system and can increase the risk of arrhythmias.
➢ Conditions not present at birth but acquired later in life:
♦ Commotio Cordis - concussion of the heart that can occur from being hit in the chest
by a ball, puck, or fist.
♦ Myocarditis - infection/inflammation of the heart, usually caused by a virus.
♦ Recreational/Performance - Enhancing drug use.
➢ Idiopathic: Sometimes the underlying cause of the Sudden Cardiac Arrest is unknown, even after
autopsy.
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