2012-13

HUMBLE INDEPENDENT SCHOOL DISTRICTUIL ATHLETIC PARTICIPATION FORM

*Please use BluelBlack ink and Print legibly*Fill in all BLANKS ... Ifitems don't apply please write N/A

RECElPT#

A completed physical must be 00 me with the Athletic Department before a student athlete can participate in any athletic activity.

All Physicals must be the ORIGINAL (can not be a copy, fax. etc.) NO FORM WILL BE ACCEP'IED BEFORE At'RIL 1,2012. This meansyour physical for the 2012-13 year must be performed on or after this date. It is the athlete's responsibility to update new information as soon as itbecomes available. (new address, phone number, etc ... )

Student ill #:------ Gender: Male I Female Date of Birth: Age: Grade (20 i2-13):

Last Name: FirstName: Home Phone: Cell Number: _

Address: City/Zip:

-----------------------------------------------------~,.... .•.•..........-------------- ~- .Circle the school that you will be attending in 2012-2013: tPORT (s)

KHS AHS HHS SCHS KPHS AMS CMS HMS KMS RMS RSMS TMS WCMS

--------------------------------------------------~,------------~ --------------~--------..MALE PARENT/ GUARDIAN: FE!vlALEPARENT/GUARDIAN:

Home Phone: Cell Phone: _ Home Phone: Cell Phone:

WorkPhone: LIVES WITH: YES NO Work Phone: LlVES WITH: YES NO

..------------------------------------------------ ..----------..'......•.-------.... ..,~•.•.•.-EMERGENCY CONTACT: Please list the emergency contact IN CASE a parentigilardian!:A..~ be reached:

Name: Home Phone: _

Cell Phone: Work Phone: _

Relationship: __________ FamilyPhysician: OfficePhone:.. ..__..__..__~ ....._,.... . .., ..HEALTH INSURANCE INFORMATION: Please provide Insurance Information for your student-athlete.

Insurance Company Name: Address:

City:------------ State: Zip: _ Phone:

Policy and/or Group Identification Numbers:

[J+- CHECK HERE IF ~ ATHl.ETE IS NO! COVERED illillER HEALTH INSURANCE AT THIS TIME

Humble Indenendent School District offers an Student Accident Insurance Policy for all Humble ISD student athletes. This insurance policyis available to all student athletes and is offered to assist in the diagnoses and/or ·treatment of any injuries that may occur from participating inathletics. This insurance is secondary to the insurance policy that the parent/or guardian has on the student athlete. It is NOT a replacementof any other insurance pol!£:.f..It is the responsibility of the paren!lguardian to request a claim form within 90 days of the injury andto submit claim form to the insurance compall.Y; Further information about this supplemental insurance can be found through the athletictrainer office at the student athlete's campus.

------------------------------ ....-------------------~-------------------------------------------- ..--MEDICATIONS:Please list ANY prescribed medlcatlcns that the student-athlete is currently taking.(Student Athletes carrying Inhalers must have a Student Asthma Action Plan on file with the Campus Nurse and/or Athletic Trainer.)

Medication Reason for Medication _

Medication Reason for Medication _

Medication Reason for Medication _o Check here if you are NOT currently taking any prescribed medications

Students Name: _Student - Parent/Guardian Section-MEDICAL mSTORY FORM must be completed annually by parent/guardian and student in order for thestudent to participate in athletic activities. These questions are designed to determine if the student has developed any condition which would make ithazardous to participate in an athletic event.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 requiresfurther medical evaluation which may include a physical examination. Written clearance from a physician. physician assiswnt chiropractor. or nursepractitioner is required before any participation in UIL practices. games. or matches

YES NO YES NO YES NOI. Have you had a medical illness or 0 0 4. (cont.) Have you ever been knocked out, 0 0 13. (cont.) Do you bave seasonal 0 0injury since your last check up or sports become unconscious, or lost your memory? allergies that require medical treatment?physical?

If YES, how many times? 14.Do you use auy special protective or 0 00 02. Have you been hospitalizedWhen was the last concussion? corrective eauipment of devices that

overnight in the past year? aren't usually used for your sport or

Have you ever had surgery? 0 0 How severe was each one? (Explain) position (for example, knee brace, specialneck loll, foot orthotics, retainer en your

3. Have you ever passed out during 0 0 0 0 teeth, hearing aid)?or after exercise? Have you ever had a seizure?

0Do you have frequent or severe headaches? 0 0

15. Have you ever had a sprain, strain,OHave you ever had chest pains 0 0 or swelling after injury?during or after exercise? Have you ever had numbness or tingling in 0 0 Have Y6U broken or fractured any ,0 0Do you get tired more quickly than 0 0

your arms, hands, legs, or feet? bones or dislocated any joints?your friends do during exercise? Have you ever had a stinger, burner, or 0 0 Have you had any problems with pain 0 0Have you ever had racing heart or 0 0 pinched nerve? or swelling in muscles, tendons, bone",skipped heartbeats? 5. Are you missing any paired organs? 0 0 joiGts?

Have you have or have had high 0 0 6. Are you under a doctor's care? 0 16. De you want to weigh more or jess 0 0blood pressure or high cholesterol? 0 than you do now?

7. Are you currently taking any prescription 0 0 Do you lose weight regularly to meet 0 0Have you ever been told you have a 0 0 or non-prescription (over-the-counter)heart murmur? medication or pills or using an inhaler? weigh! requirements for your sport?

Has any family member or relative 0 0 8.Do you have any allergies? (for example, to 0 0 17. Do you feel stressed out? 0 0died of heart problems or of sudden pollen, medicine, food, or insects) 18.Have yO~1ever been diagnosed with 0 0unexpected death before age 50? !

9. Have you eyer become dizzy during or 0 0 or treated for sickle cell trait or sickle cellHas any family member been after exercise? disease?diagnosed with enlarged heart 0 0 10. Do y01~have any current skin problems? Females Only:hypertrophic cardiomyopathy, long 0 0QT syndrome, Marfan's syndrome, (itching, rashes, acne, warts, fungus, blisters) 19. When was your first menstrual period?or abnormal heart rhythm? 11. Have YO!l ever become ill from exercising 0 0Have you had a severe viral infection 0 0 in the heat? When was your most recent menstrual period?(for example myocarditis or 12. Have you ever had any problems witn 0 0mononucleosis) within the last your eyes or vision? How much time do you usually have from themonth?

13. Have you ever gotten unexpectedly 0start of one period to the start of another?

Has a physician ever denied or 0 0 0short of breath with exercise?restricted your participation in

0 0 How many periods have you had in the lastsports for any heart related Do .vau have asthma?year?problems?

If YES, is an inhaler required by you~ 004.Have yO? ever.' had a hea~ injury 0 0 physician, (Must have Inhaler Action PlanWhat the longest time between periods in theor concussion? . on f;le.) SEE BELOWlast year?

Explain "YES" answers here?

For School Use Only:This Medical History Form was reviewed by: Frint Name: _______ Date: Signature _

Asthma NotificationStudents that are required to carry an inhaler for Asthma are to obtain a secondary inhaler for the sport(s) they wish to participate. The secondary inhaler is tobe an emergency back up to the inhaler the student athlete carries with them. The emergency inhaler is to be kept with the coach ofthe sport(s) the studentathlete participates in. A Student Asthma Action Plan must be kept on file with the campus nurse and/or with the Athletic Trainer for those student athletesthat carry an inhaler. The form can be obtained through the campus nurse and/or the athletic trainer.

o ~Check here if student IS required to carry an inhaler. 0~Check here is student IS NOT required to carry an inhaler.

Medical Examiner SectionHumble ISD requires an annual pbysical exam.

Students Name: Sex Age __ Date of Birth Height_- ___ Weight---Pulse BP 1 ~ __ :__ I_'----.J

Vision: R -201 L-201 Corrected Y N Contacts 1 Glasses Pupils Equal/Unequal

Medical Normal Abnormal InitialsAppearanceEyes/EarsN ose/Throat ,Lymph Nodes \Heart- Auscultation Supine , I '.Heart - AuscultationStanding r ~ ,

Heart -Lower ExtremityPulsesLungs --~---f -~Abdomen fGenitalia (males only) \

Skin q=Marfan's Stigmata (arachnodactyly, pectus \

excauatum,joint hyperobility, scoliosis) \ I --Musculoskeletal Normal Abnormal \ Initials

NeckBack \

Shoulder/ArmElbowlForearrn ,WristlHand \ \

Knee " \ .~

"Leg Ankle

~

\ 1

Foot -I

Clearance: NOTE OF CL1~ARANCE lVIUST BE ON LETTERHEAD OF CLEARING PHYSiCIANDclearedOcleared after completing evaluation/rehabilitation for:D Not Cleared for:

\

Reason: "Recommendations: , -

The following information mustie filled in and signed by either a Physician, a Physician Assistant licensed by a State Board of Physician Assistant Examiners, a RegisteredNurse 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 practitionerwill not be accepted.Date of Examination: Address:

\ ,Name: (print/type): __________________ Phone Number:

Physician's Signature: _________________ PLEASE INCLUDE PHYSICIAN STAMP

Please list any recent injuries that required CLEARA~CE from a doctor:

~-----'---

INJlJRY INFORMATION:If the athlete is referred to a physician, or chooses to visit II physician on their own, documentation must be provided to the proper people.. ,- High School: Athletic trainers- Middle School: the Head Coach of the sport you are participating in.The documentation is to include the following;,- Diagnosis- Status - Not only what you can't do, but also what you can do.- Treatment Options - High School Athletics only,- Next appointment date.This documentation is necessary to ensure that the athlete is medically able and cleared to participate. The guidelines outlined in the documentation will be the onesfollowed until another notice is received from the athletes' physician. If a coach or trainer discovers that an athlete was examined by a physician without providingdocumentation, they will not be allowed to participate or be provided further treatment or rehabilitation until the proper documentation is received.

,.'

Certain types of visits to a physician's office do n!lt require you to provide a note. For example:- Lab work, dependant upon the nature of'the tests being performed. - Allergy shots,

** MIDDLE SCHOOL STUDENTS ONLY**Middle School Students (going to the 7th and 8th grades only) return all completed forms to the HEAD COACH. After turning your physicalinto the HEAD COACH they will give you a receipt. BE SURE TO KEEP A RECEIPT FOR YOUR RECORDS

**IDGH SCHOOL STUDENTS ONLY (9-12)**Neurocognitive Testing Authorization (for parent and athlete)

Humble ISD will be utilizing ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) for pre-season. baseline testing(contact sports) and post-injury testing (all sports) as a tool in the concussion management protocol. ImPACT is a non-invasive test that isessentially a preseason physical for the brain. ImP ACT tests memory, reaction time, speed and concentration. ImP ACT provides us the bestavailable information for managing concussions and preventing potential brain damage that can occur with multiple concussions. By signingbelow you agree to participate n the ImP ACT Concussion Management Program.

Athlete's Name (print): Athlete's Signature:

Parent/Guardian's Name: Parent/Guardian's Signature: \

\

Please list any MTBIIConcussions over the last 2 years with date and days missed (if known)

\ ,

For Athletic Trainer Use ONLY:Date of Baseline # 1: Date of Baseline #2:

University Interscholastic League Steroid AgreementParent and Student Agreement! Acknowledgement - Anabolic Steroid USt~and Random Steroid Testing

• Texas state law prohibits possessing, dispensing, delivering a steroid in a manner not allowed by state law,• Texas state law also provides that body building, muscle enhancement or increase in muscle bulk or strength through the use of steroid by a person in

good health is not a valid medical purpose.• Texas state law requires that only a licensed practitioner with prescriptive authority may prescribe a steroid lor a person.• Any violation of state law concerning steroids is a criminal offense punishable by confinement injail or imprisonment in the Texas Department of

Criminal Justice.

Student Acknowledgment and AgreementAs a prerequisite to participation in UlL athletic activities, I agree that I will not use anabolic steroids as defined in the Ufl, Anabolic Steroid TestingProgram Protocol. I have read this form and understand that I may be asked to submit to testing for the presence of anabolic steroids in my body, and I dohereby agree to submit to such testing and analysis oy a certified laboratory. I further understand and agree that the results of the steroid testing may beprovided to certain individuals in my high school as specified in the UIL Anabolic Steroid Testing Program Protocol which is available on the UIL website atwww.uiltexas.org. I understand and agree that the resuits of steroid testing will be held confidential to the extent required by law. I understand that failure toprovide accurate and truth.ul information could subject me to penalties as derermined by UIL.

Student (print) , Grade (9-12) _____ Student Signature: Date:

Parent/Guardian (Print):______________ Relationship: Signature: Date:.....-...-.~..•.,--....-.:**IllGH SCHOOL STUDE}J1S INCLUDING THOSE GOING IN TO THE 9TH GRADE**

Return your completed form to your campus athletic training mom. ** DO NOT GfVE ANY FORMS TO COACHES** After turning in yourphysical into the ATHLETIC TRAl.l'ffiR keep the wnite receipt and lake the yellow receipt to the HEAD COACH of the first sport you're going toparticipate. Keep the white receipt for your records and any other sports you may want to participate in. You must have a YELLOW receipt to giveyour HEAD COACH before you will be allowed to participate in ANY UIL in-season or off-season sport(s).

**DO NOT LOSE YOUR warn: RECEIPT. TIns IS PROOF YOU TURNED IN A PHYSICAL FORM!**...............................•............ ~

lfyou have any other questions aboutthis form, including SUMMER turn in locations and times ... Please call the Humble ISD Athletic Office at281-641-8130 or your campus athletic training room.Atascocita HS 281.641.7655Humble HS 281.641.6510 hh.~trainjngroom(a)gm3il.comKingwoodHS 281.641.7028 www.hisdmustanas.com

Kingwood Park HS 281.641.6738 www.kparksoortsmedicine.comSummer Creek US 281.641.5441 www.humbleisd.net/schssportsmedicine.

IDGH SCHOOL AND MIDDLE SCHOOL PARENTS by signing below you are stating that all information on this form is correct.Falsifying or forging any information can make the student-athlete ineligible for athletics.

Parent Signature