AT-001-13 REVISED 05/08/2012 |
01.32.0350 |
Arlington I.S.D. Athletic Participation Release |
No student will be permitted to participate in any practice, off-season program, or contest prior to this document and a current physical examination being on file with the athletic trainer or coach at the student’s school
AISD policy requires the completion of an annual physical exam
Last Name:__________________________________ First Name:_____________________________ Sex: M F Date of Birth ____/____/____
Grade (Entering) 7th 8th 9th 10th |
11th 12th |
School Year _____-_____ Student Age_____ |
|
Please Check all sports/activities in which student is planning to participate: |
|
|
|
Football |
Volleyball |
Basketball |
Soccer |
Baseball |
Softball |
Cross Country |
Track |
Golf |
Tennis |
Wrestling |
Swimming |
Other ______________________ |
Address:___________________________________________________Apt#____________ City:_______________________ Zip:_____________
Home Telephone:_______________________________________________________________________ Student ID:_______________________
Mother/Guardian:____________________________________Work Phone:_________________________________Cell Phone:________________
Father/Guardian:_____________________________________Work Phone:_________________________________Cell Phone:________________
Emergency Contact:_________________________________________Phone:_____________________________________Relation:___________________________
Primary Care Physician:____________________________________________________________Phone:_________________________________________________
Insurance Company:_____________________________________________________Policy and/or Group#_______________________________________________
NOTICE TO FOOTBALL PARTICIPANTS ONLY
Do not use your helmet to butt, ram or spear the opposing players. This is in violation of the football rules and can result in severe head, brain or neck injury, paralysis or death to you and possible injury to your opponent. There is a risk these injuries may also occur as a result of accidental contact without intent to butt, ram, or spear.
PARENT/GUARDIAN PERMIT, UIL RULES AND INSURANCE NOTICE
I have read the following University Interscholastic League rules and agree that my son/daughter will abide by all of the University Interscholastic League rules. According to UIL standards, students are eligible to represent their school in Interscholastic activities if they: 1)are not 19 years of age or older on or before Sept. 1 of the current school year(See 504 handicapped exception.)2)have not graduated from high school 3)are enrolled by the sixth class day of the current school year or have been in attendance for fifteen calendar days preceding a varsity contest 4)are full-time day students in a participant high school 5)initially enrolled in the ninth grade not more than four calendar years ago 6) are meeting academic standards required by state law 7)live with their parents inside the school district attendance zone their first year of attendance(varsity eligibility only)8)have observed all provisions of the Awards Rule 9)have not represented a college in a contest 10) have not been recruited 11)have not violated any provision of the summer camp rule(incoming 10-12 grade students shall not attend a baseball, basketball, football, soccer, or volleyball camp in which a seventh through twelfth grade coach from their school district attendance zone, works with, instructs, transports or registers that student in the camp. Students who will be in grades 7,8 and 9 may attend one baseball, one basketball, one football, one soccer, one softball, and one volleyball camp in which a coach from their school district attendance zone is employed, for no more than six consecutive days each summer in each type of sport camp. Baseball, Basketball, Football, Soccer, Softball, and Volleyball camps where school personnel work with their own students may be held in May, after the last day of school, June, July and August prior to the second Monday in August. If such camps are sponsored by school district personnel, they must be held within the boundaries of the school district and the superintendent or his designee shall approve the schedule of fees.)12)have observed all provisions of the Athletic Amateur Rule. Students may not accept money or other valuable consideration for participating in any athletic sport during any part of the year. Students who inadvertently violate the amateur rule by accepting valuable consideration may regain athletic eligibility by returning the valuable consideration. If they fail to return it within 30 days, they remain ineligible for one year from when they accepted it. During the time from when students receive valuable consideration until they return it, they are ineligible for varsity athletic competition in the violation occurred. Minimum penalty for participating in a contest while ineligible is forfeiture of the contest. 13) did not move for athletic purposes.
I have read and understand the rules on this form and agree to abide by all of the UIL rules. Any violation of policies or rules of the AISD, UIL, AISD Handbook and the local building principal may be grounds for immediate probation or dismissal.
Student Signature:________________________________________________
I have completed theDWWDF HGMedical History form and affirm that it is correct. I have read and understand the UIL rules on this form and agree that my son/daughter will abide by all the UIL rules.
The above named student is now under my control and in my custody. I hereby give my consent for the above named student to compete in University Interscholastic League or Arlington Independent District approved sports and to go with the Coach or other representative of the school, or any parent, on any field trips. THE PARENT
HEREWITH GRANTS PERMISSION FOR SCHOOL EMPLOYEES TO SECURE MEDICAL SERVICES FOR THE ABOVE NAMED STUDENT 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. In consideration of the above named student being permitted to make such trips and take part in such activities; I hereby release the University Interscholastic League and the Arlington Independent School District, its Trustees, Superintendent, Principals, Teachers, and employees together with all persons, both employees and volunteers, including parents assisting with any phase of such trips and activities(excluding paid certificated carriers) from all liability and responsibility in connection with such trips and activities and hereby release all of said parties from all liability by reason of any accident, injuries or losses suffered by said student while on said trip or participating in such activities, including athletic events, related activities, including travel, and I agree to indemnify and hold all of said parties harmless from all claims hereafter made or asserted by or on behalf of the above named student and his/her parents, heirs, executors or assigns.
If between this date and the beginning of athletic competition, any illness or injury should occur that may limit the students participation I agree to notify the school authorities of such illness or injury.
The undersigned hereby agrees to be responsible for the safe return of all athletic equipment issued by the school to the above named student. I also authorize any physician to release confidential information concerning any athletic injury to the Athletic Trainer involved.
I understand that Arlington Independent School District does not provide accident insurance for an athlete to cover injuries sustained by the student, before, during or after any sporting event or practice. I understand that I will need to provide insurance of my own.
We will provide our student with insurDnce
3DUH W*XDUGLD 'DWH
******************************************************************************************************************
TO BE COMPLETED IN THE PRESENCE OF A NOTARY
Parent/Guardian Signature:______________________________________________________Date:_______________________
Subscribed and Sworn this ______day of_________________________20___Notary State of Texas:____________________________
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.
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. 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 |
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 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? |
|
|
|
Have you ever been knocked out, become unconscious, or lost |
|
|
|
your memory? |
|
|
|
|
|
If yes, how many |
When was the last |
|
|
|
times? |
|
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 |
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. |
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)? |
|
|
|
15. |
Have you ever had a sprain, strain, or swelling after injury? |
|
|
|
Have you broken or fractured any bones or dislocated any |
|
|
|
joints? |
|
|
|
|
|
Have you had any other problems with pain or swelling in |
|
|
|
muscles, tendons, bones, or joints? |
|
|
|
|
If yes, check appropriate box and explain below. |
|
|
|
Head |
Elbow |
Hip |
|
|
|
Neck |
Forearm |
Thigh |
|
|
|
Back |
Wrist |
Knee |
|
|
|
Chest |
Hand |
Shin/Calf |
|
|
|
Shoulder |
Finger |
Ankle |
|
|
|
Upper Arm |
|
Foot |
|
|
16. Do you want to weigh more or less than you do now? |
|
|
|
Do you lose weight regularly to meet weight requirements for |
|
|
|
your sport? |
|
|
|
|
17. Do you feel stressed out? |
|
|
|
18. Have you ever been diagnosed with or treated for sickle cell trait |
|
|
|
or sickle 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: ________________
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 ______________________________Date____________ Signature_______________________________
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: |
Y |
N |
Pupils: |
Equal |
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* |
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)
Skin
Marfan’s stigmata (arachnodactyly, pectus excavatum, joint hypermobility, scoliosis)
MUSCULOSKELETAL
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand
Hip/Thigh
Knee
Leg/Ankle
Foot
*station-based examination only
CLEARANCE
Cleared
Cleared after completing evaluation/rehabilitation for: __________________________________________________________
_________________________________________________________________________________________________________
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 games/matches.
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 ________________
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 UIL 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 |
Football |
Softball |
Basketball |
Golf |
Swimming & Diving |
Cross Country |
Soccer |
Team Tennis |
Wrestling |
|
|
Tennis
Track & Field
Volleyball
Date_________________
Signature of parent or guardian__________________________________
Street address________________________________________________
City________________________ State _______________ Zip ______________
Home Phone ________________________ Business Phone ________________________
Revised January 2011
GENERAL INFORMATION
School coaches may not:
• Transport, register, or instruct students in grades 7-12 from their attendance zone in non-school baseball, basketball, football, soccer, softball, or volleyball camps (exception: See Section 1209 of the Constitution and Contest Rules).
• Give any instruction or schedule any practice for an individual or a team during the off-season except during the one in school day athleticperiod in baseball, basketball, football, soccer, softball, or volleyball
• Schools and school booster clubs may not provide funds, fees, or transportation for non-school activities.
GENERAL ELIGIBILITY RULES
According to UIL standards, students could be eligible to represent their school in interscholastic activities if they: • are not 19 years of age or older on or before September 1 of the current scholastic year. (See Section 446 of the
Constitution and Contest Rules for exception). • have not graduated from high school.
• are enrolled by the sixth class day of the current school year or have been in attendance for fifteen calendar days immediately preceding a varsity contest.
• are full-time students in the participant high school they wish to represent. • initially enrolled in the ninth grade not more than four years ago.
• are meeting academic standards required by state law.
• live with their parents inside the school district attendance zone their first year of attendance. (Parent residence applies to varsity athletic eligibility only.) When the parents do not reside inside the district attendance zone the student could be eligible if: the student has been in continuous attendance for at least one calendar year and has not enrolled at another school; no inducement is given to the student to attend the school (for example: students or their parents must pay their room and board when they do not live with a relative; students driving back into the district should pay their own transportation costs); and it is not a violation of local school or TEA policies for the student to continue attending the school. Students placed by the Texas Youth Commission are covered under Custodial Residence (see Section 442 of the Constitution and Contest Rules).
• have observed all provisions of the Awards Rule.
• have not been recruited. (Does not apply to college recruiting as permitted by rule.)
• have not violated any provision of the summer camp rule. Incoming 10-12 grade students shall not attend a baseball, basketball, football, soccer, or volleyball camp in which a seventh through twelfth grade coach from their school district attendance zone, works with, instructs, transports or registers that student in the camp. Students who will be in grades 7, 8, and 9 may attend one baseball, one basketball, one football, one soccer, one softball, and one volleyball camp in which a coach from their school district attendance zone is employed, for no more than six consecutive days each summer in each type of sports camp. Baseball, Basketball, Football, Soccer,Softball, and Volleyball camps where school personnel work with their own students may be held in May, after the last day of school, June, July and August prior to the second Monday in August. If such camps are sponsored by school district personnel, they must be heldwithin the boundaries of the school district and the superintendent or his designee shall approve the schedule of fees.
• have observed all provisions of the Athletic Amateur Rule. Students may not accept money or other valuable consideration (tangible or intangible property or service including anything that is usable, wearable, salable or consumable) for participating in any athletic sport during any part of the year. Athletes shall not receive valuable consideration for allowing their names to be used for the promotion of any product, plan or service. Students who inadvertently violate the amateur rule by accepting valuable consideration may regain athletic eligibility by returning the valuable consideration. If individuals return the valuable consideration within 30 days after they are informed of the rule violation, they regain their athletic eligibility when they return it. If they fail to return it within 30 days, they remain ineligible for one year from when they acceptedit. During the period of time from when students receive valuable consideration until they return it, they are ineligible for varsity athletic competition in the sport in which the violation occurred. Minimum penalty for participating in a contest while ineligible is forfeiture of the contest.
• did not change schools for athletic purposes.
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.
I have read the regulations cited above and agree to follow the rules.
____________________ |
________________________________________________________________ |
Date |
Signature of student |
Acknowledgement of Rules Form |
Page 2 |
University Interscholastic League
Parent and Student Agreement/Acknowledgement Form
Anabolic Steroid Use and Random Steroid Testing
∞Texas state law prohibits possessing, dispensing, delivering or administering a steroid 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 licensed 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 Department of Criminal Justice.
STUDENT ACKNOWLEDGEMENT AND AGREEMENT
As a prerequisite to participation in UIL athletic activities, I agree that I will not use anabolic steroids as defined in the UIL Anabolic Steroid Testing Program 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 do hereby agree to submit to such testing and analysis by a certified laboratory. I 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 UIL Anabolic Steroid Testing Program Protocol which is available on the UIL website at www.uiltexas. U . I understand and agree that the results of steroid testing will be held confidential to the extent required by law. I 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 Signature: _____________________________ Date: ___________
PARENT/GUARDIAN CERTIFICATION AND ACKNOWLEDGEMENT
As a prerequisite to participation by my student in UIL athletic activities, I certify and acknowledge that I have read this form and understand that my student must refrain from anabolic steroid use and may be asked to submit to testing for the presence of anabolic steroids in his/her body. I do hereby agree to submit my child to such testing and analysis by a certified laboratory. I further understand and agree that the results of the steroid testing may be provided to certain individuals in my studentÕs high school as specified in the UIL Anabolic Steroid Testing Program Protocol which is available on the UIL website at www.uiltexas. U . I understand and agree that the results of steroid testing will be held confidential to the extent required by law. I understand that failure to provide accurate and truthful information could subject my student to penalties as determined by UIL.
Name (Print): ___________________________________________
Signature: _____________________________ Date: ___________
Relationship to student: ___________________________________
Rev. April, 2012
CONCUSSION ACKNOWLEDGEMENT FORM
Name of Student
Deinition of Concussion - means a complex pathophysiological process afecting the brain caused by a traumatic physical force or impact to the head or body, which may: (A) include 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 technique.
–Follow the rules of play.
–Make sure the required protective equipment is worn for all practices and games.
–Protective equipment must it properly and be inspected on a regular basis.
Signs and Symptoms of Concussion – he signs and symptoms of concussion may include but are not limited to: Head ache, appears to be dazed or stunned, tinnitus (ringing in the ears), fatigue, slurred speech, nausea or vomiting, dizziness, loss of balance, blurry vi- sion, sensitive to light or noise, feel foggy or groggy, memory loss, or confusion.
Oversight - Each district shall appoint and approve a Concussion Oversight Team (COT). he COT shall include at least one physician and an athletic trainer if one is employed by the school district. Other members may include: Advanced Practice Nurse, neuropsy- chologist or a physician’s assistant. he COT is charged with developing the Return to Play protocol based on peer reviewed scientiic evidence.
Treatment of Concussion - he student-athlete shall be removed from practice or competition immediately if suspected to have sus- tained a concussion. Every student-athlete suspected of sustaining a concussion shall be seen by a physician before they may return to athletic participation. he treatment for concussion is cognitive rest. Students should limit external stimulation such as watching television, playing video games, sending text messages, use of computer, 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 may begin their district’s Return to Play protocol 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 under Section 38.156 may not be permitted to practice or compete again following the force or impact believed to have caused the concussion until:
(1)the student has been evaluated, using established medical protocols based on peer-reviewed scientiic evidence, by a treating physi- cian 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 protocol 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 student 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;
(ii)understands the risks associated with the student returning to play and will comply with any ongoing requirements in the return-to-play protocol;
(iii)consents to the disclosure to appropriate persons, consistent with the Health Insurance Portability and Accountability Act of
1996 (Pub. L. No. 104-191), of the treating physician ’s written statement under Subdivision (3) and, if any, 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 |
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:
♦Lonq 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.
NonInherited (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.
1
SUDDEN CARDIAC ARREST AWARENESS FORM
Revised June 2013
What are the symptoms/warning signs of Sudden Cardiac Arrest?
Fainting/blackouts (especially during exercise)
Dizziness
Unusual fatigue/weakness
Chest pain
Shortness of breath
Nausea/vomiting
Palpitations (heart is beating unusually fast or skipping beats)
Family history of sudden cardiac arrest at age < 50
ANY of these symptoms/warning signs that occur while exercising may necessitate further evaluation from your physician before returning to practice or a game.
What is the treatment for Sudden Cardiac Arrest?
Time is critical and an immediate response is vital.
CALL 911
Begin CPR
Use an Automated External Defibrillator (AED)
What are ways to screen for Sudden Cardiac Arrest?
The American Heart Association recommends a pre‐participation history and physical including 12 important cardiac elements.
The UIL Pre‐Participation Physical Evaluation – Medical History form includes ALL 12 of these important cardiac elements and is mandatory annually.
Additional screening using an electrocardiogram and/or an echocardiogram is readily available to all athletes, but is not mandatory.
Where can one find information on additional screening?
American Heart Association (www.heart.org)
August Heart (www.augustheart.org)
Championship Hearts Foundation (www.championshipheartsfoundation.org)
Cypress ECG Project (www.cypressecgproject.org)
Parent Heart Watch (www.parentheartwatch.com)
____________________________________________ |
_________________________________________ |
Parent/Guardian Signature |
Date |
____________________________________________ |
|
Parent/Guardian Name (Print) |
|
____________________________________________ |
_________________________________________ |
Student Signature |
Date |
____________________________________________ |
|
Student Name (Print) |
|
2
