Must be an original
The form must be
printed to scale on
8 1/2 x 11 sheet of
paper
Previous forms invalid - Revised 07/20/15
Houston Independent School District
Athletic Department
Athletic Insurance Waiver
Check the correct box
2015-2016 School Year
School
2016-2017 School Year
Sport
Before me, the undersigned authority, a Notary Public in and for Harris County, Texas, personally
appeared
, who being by me duly sworn, upon
oath say/says:
Our Names are/My name is
, and we/I reside at
, within the boundaries of the
Houston Independent School District in Harris County, Texas. We/I am the parent or legal guardian
of
, a student attending the public
schools of the Houston Independent School District. We/I have been advised that as a matter of policy
the Houston Independent School District has required all students in the secondary schools who
participate in interscholastic sports to participate in the personal injury insurance program of the school
district. In addition, the Houston Independent School District has agreed to pay an additional premium to
have all middle and high school athletes fully covered while participating in all sports. We/I further
understand that HISD, as well as its Board of Trustees, its agents, and its employees, by implementing
this policy and purchasing this insurance, are in no way waiving their governmental immunity from suit
and are not assuming liability for any injuries, medical expenses, or damages which may arise from
students' participation in athletics.
Our/My child,
, is covered by hospitalization
and accident insurance through the
insurance company at
my place of employment, or through
insurance
company where my spouse is employed. We/I carry this coverage on our/my child in the event he/she is
injured and there will be sufficient insurance to cover any expenses incurred in connection with this injury.
For us/me to be required to contribute any sum of money for a duplicate insurance coverage through the
school district would be of no benefit to us or to our child.
In view of the foregoing, we/I hereby waive for all purposes the necessity that our /my child,
, be required to participate in the insurance program
provided by the Houston Independent School District. We/I recognize this insurance is available;
however, we/I have made a choice to see that our child is covered by insurance of our/my own choice
rather than to participate in the program offered through the school district. In the event of an injury to
our/my child, we/I recognize that the Houston Independent School District, its Board of Trustees, its
agents, and its employees, are in no way liable for any injuries, medical expenses, or damages and will
have no insurance with regard to our/my child, and we/I have made this choice of an insurance program,
feeling that it is in the best interest of our/my child and of our /my family.
We/I acknowledge that we/I have had an opportunity to make this choice on behalf of child
without any interference from the Board of Trustees or the administration of the Houston Independent
School District, and this choice is our/my personal preference, taking into consideration all the foregoing.
Dated this
day of
, 20
X
.
X
Father of
Mother of
(student's name)
(student's name)
X
Guardian of
(student's name)
Subscribed and sworn to before me and by the said
the
day of
, 20
and
, the mother and father, or legal guardian of
, a student in the Houston Independent School District, this
to certify which witness my hand and seal of office.
Notary Public in and for Harris County, Texas
or School Administrator/HISD Administrator
(Notary Seal)
Original – Athletic Department
Principal
witnesses
signature
Copies – Coach/Sponsor and Parent
Fill out completely
PREPARTICIPATION PHYSICAL EVALUATION -- MEDICAL HISTORY
REVISED 12-4-14
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.
Student's Name: (print)
Sex
Age
Date of Birth
Address
Phone
Grade
School
Personal Physician
Phone
In case of emergency, contact:
Name
Relationship
Phone (H)
(W)
Explain “Yes” answers in the box below**. Circle questions you don’t know the answers to.
1. Have you had a medical illness or injury since your last check
up or sports physical?
2. Have you been hospitalized overnight in the past year?
Have you ever had surgery?
3. Have you ever had prior testing for the heart ordered by a
physician?
Have you ever passed out during or after exercise?
Have you ever had chest pain during or after exercise?
Do you get tired more quickly than your 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 a heart murmur?
Has any family member or relative died of heart problems or of
sudden unexpected death before age 50?
Has any family member been diagnosed with enlarged heart,
(dilated cardiomyopathy), hypertrophic cardiomyopathy, long
QT syndrome or other ion channelpathy (Brugada syndrome,
etc), Marfan's syndrome, or abnormal heart rhythm?
Have you had a severe viral infection (for example,
myocarditis or mononucleosis) within the last month?
Has a physician ever denied or restricted your participation in
sports for any heart problems?
4. Have you ever had a head injury or concussion?
4. Have you ever been knocked out, become unconscious, or lost
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?
Do you have frequent or severe headaches?
Have you ever had numbness or tingling in your arms, hands,
legs or feet?
Have you ever had a stinger, burner, or pinched nerve?
5. Are you missing any paired organs?
6. Are you under a doctor’s care?
7. Are you currently taking any prescription or non-prescription
(over-the-counter) medication or pills or using an inhaler?
8. Do you have any allergies (for example, to pollen, medicine,
food, or stinging insects)?
9. Have you ever been dizzy during or after exercise?
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?
Yes
No
o
o
o
o
o
o
o
o
14.
o
o
o
o
o
o
15.
o
o
o
o
o
o
o
o
joints?
Have you had any other problems with pain or swelling in
o
o
o
Yes
13.
No
Have you ever gotten unexpectedly short of breath with
exercise?
Do you have asthma?
Do you have seasonal allergies that require medical treatment?
Do you use any special protective or corrective equipment or
devices that aren't usually used for your sport or position (for
example, knee brace, special neck roll, foot orthotics, retainer
on your teeth, hearing aid)?
o
o
o
o
o
o
o
Have you ever had a sprain, strain, or swelling after injury?
Have you broken or fractured any bones or dislocated any
o
o
o
o
o
o
o
o
o
o
o
o
o
muscles, tendons, bones, or joints?
If yes, check appropriate box and explain below:
o
o
o
o
o
o
16.
17.
o
o
o
o
18.
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Head
o
o
Elbow
Hip
o Neck
o Forearm
o Thigh
o Back
o Wrist
o Knee
o Chest
o Hand
o Shin/Calf
o Shoulder
o Finger
o Ankle
o Upper Arm
o Foot
Do you want to weight more or less than you do now?
Do you feel stressed out?
Have you ever been diagnosed with or treated for sickle cell
trait or cell disease?
Females only
19. When was your first menstrual period? _____________
When was your most recent menstrual period? _____________
How much time do you usually have from the start of one period to the start of
another? _____________
How many periods have you had in the last year? _____________
What was the longest time between periods in the last year? _____________
An individual answering in the affirmative to any question relating to a possible cardiovascular health
issue (question three above), as identified on the form, should be restricted from further participation
until the individual is examined and cleared by a physician, physician assistant, chiropractor, or nurse
practitioner.
**EXPLAIN ‘YES’ ANSWERS IN THE BOX BELOW (attach another sheet if necessary):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
__________
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.
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:
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. THIS FORM MUST BE ON FILE PRIOR TO
PARTICIPATION IN ANY PRACTICE, SCRIMMAGE OR CONTEST BEFORE, DURING OR AFTER SCHOOL.
For School Use Only:
This Medical History Form was reviewed by: Printed Name
Student
Date
Parent
Signature
Date
PREPARTICIPATION PHYSICAL EVALUATION -- PHYSICAL EXAMINATION
Student's Name _________________________________ Sex _______ Age _______ Date of Birth _________________________
Height ______
Weight________
% Body fat (optional) ________
Pulse __________
BP____/____ (____/____, ____/____)
brachial blood pressure while sitting
Vision: R 20/______ L 20/___
Corrected:
o Y
o N
Pupils:
o Equal
o Unequal
As a minimum requirement, this Physical Examination Form must be completed prior to junior high athletic participation and
again prior to first and third years of high school athletic 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*
Lymph
Heart-Auscultation of the heart
the supine
Heart-Auscultation of the heart
the standing
Heart-Lower extremity
Genitalia (males
Marfan’s stigmata
pectus excavatum,
hypermobility,
MUSCULOSKELETAL
*station-based examination only
CLEARANCE
Must be checked
by Doctor
o
Cleared
o
Cleared after completing evaluation/rehabilitation for: __________________________________________________________
_________________________________________________________________________________________________________
o
Not cleared for:_________________________________________Reason: _________________________________________
Recommendations: _________________________________________________________________________________________
_________________________________________________________________________________________________________
Exam is
good for one
Physician Assistant Examiners, a Registered Nurse recognized as an Advanced Practice Nurse by the Board of Nurse Examiners,
calendar
or a Doctor of Chiropractic. Examination forms signed by any other health care practitioner, will not be accepted.
year
The following information must be filled in and signed by either a Physician, a Physician Assistant licensed by a State Board of
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 games/matches.
Doctor Signature
HOUSTON INDEPENDENT SCHOOL DISTRICT
ATHLETIC DEPARTMENT
5/2015
PARENT’S APPROVAL FOR PARTICIPATION IN ATHLETICS AND EMERGENCY MEDICAL AUTHORIZATION
I hereby certify that
has my approval to play at home or away from
(Student)
home on the athletic teams of the
follows:
Middle/High School, grade
, as
(School)
Baseball/Basketball/Cheerleader/CrossCountry/Football/Golf/Soccer/Softball/Swimming/Tennis/Track/Volleyball/Wrestling
(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
Home Address
Signed
(Parent or Guardian)
Date
Telephone
Home Address
Signed
(Parent or Guardian)
I certify that this release was signed in my presence.
Principal or Notary (no stamped signature)
(first year of participation requirement)
Notary required
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 st udent
attends. Thereafter, a parent approval signed by the parents or parent must be submitted before the student may participate.
Fill out
completely
Student Media Consent and Release Form
Throughout the school year, students may be highlighted in efforts to promote HISD activities
and achievements. For example, students may be featured in materials to train teachers and/or
increase public awareness of our schools through newspapers, radio, TV, the web, DVDs,
displays, brochures, and other types of media.
I, as the parent or guardian of ________________, hereby give HISD and its
employees, representatives, and authorized media organizations permission to print,
photograph, and record my child for use in audio, video, film, or any other electronic,
digital and printed media.
a. This is with the understanding that neither HISD nor its representatives will
reproduce said photograph, interview, or likeness for any commercial value or
receive monetary gain for use of any reproduction/broadcast of said photograph
or likeness. I am also fully aware that I will not receive monetary compensation
for my child’s participation.
b. I further release and relieve HISD, its Board of Trustees, employees, and other
representatives from any liabilities, known or unknown, arising out of the use of
this material.
I certify that I have read the Media Consent and Release Liability statement and fully
understand its terms and conditions.
Please understand that failure to return this release form within ten (10) school
days from the date of distribution will constitute approval of the above requests.
Please Print
Name of child __________________________________________ Grade___________
Address _______________________________________________________________
City, State, Zip__________________________________________________________
Signature of parent or guardian ____________________________________________
Date____________________ Phone Number ________________________________