Socorro ISD Physical Packet Student Athlete Information Sheet (Clearly Print all information in Black or Blue Ink only.)

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1 Socorro ISD Physical Packet Student Athlete Information Sheet (Clearly Print all information in Black or Blue Ink only.) School ID #: Grade: Graduation Date: Name: M ( ) F ( ) Date of Birth: Age: Home Address: Zip Code: Home Phone #: List Sport(s) or Activities involved in: Legal Guardians Name and Phone # Information: Father: Name: Place of Employment: Home Phone #: Cell #: Work #: Mother: Name: Place of Employment: Home Phone #: Cell #: Work #: Emergency Contact: Name: Relationship: Home Phone #: Cell #: Work #: Check any Medical Problems your child may have: Asthma Epilepsy Diabetes High Blood Pressure Sickle Cell Kidney Problems List ANY other problems not mentioned: Name of Doctor prescribing meds: Check any allergies your child may have: None Erythromycin Ampicillin Tetracycline Penicillin Sulfa Codeine Aspirin Foods Other Allergies: Consent Statement Authorizing Treatment I/ we give permission to duly authorized school personnel and medical doctors to render appropriate medical treatment for any injury sustained during a scheduled practice, game, or supervised school approved trip; should it be necessary to do so. Parent/ Legal guardian Signature: Date: revised March 2013

2 *Please Read Carefully* Socorro ISD Physical Packet Warning, Agreement to Follow Instructions, Release, Assumption of Risk, and Agreement to Hold Harmless Student / Parent: I / We are aware that playing or practicing to play / participate in any sport can be a dangerous activity involving MANY RISKS OF INJURY. I / We understand that the dangers and risks of playing or practicing to play / participate in the sports / activities include but are not limited to: death, serious neck and spinal injuries which may result in complete or partial paralysis, brain damage, serious injury to virtually all internal organs, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the muscular skeletal system, and serious injury impairments to other aspects of the body, general health, and well-being. I understand that the dangers and risks of playing or practicing to play / participate in sport(s) may result not only in serious injuries, but in a serious impairment of my future abilities to earn a living, to engage in other business, social and recreational activities, and to generally enjoy life. Because of the dangers of participating in sport(s), I recognize the importance of following coaches instructions regarding playing techniques, training and other team rules, etc., and to agree to follow such instructions. I am aware that if my son/daughter is going to participate in one of the following sports: (Football, Basketball, Soccer, Wrestling, Baseball, Softball). They are participating in a violent contact sport involving even greater risk than other sports in Socorro ISD. In consideration of the Socorro Independent School District permitting me to try out for any Socorro ISD athletic team(s), to engage in all activities related to the team(s), including but not limited to, trying out, practicing, or playing/participating in that sport. I hereby assume all the risks associated with participation and agree to hold Socorro Independent School District, its employees, agents, representatives, coaches, licensed athletic trainers, and volunteers harmless from any and all liability, actions, causes of actions, debts, claims, or demands of any kind and nature whatsoever which may arise by or in connection with my participation in any activities related to the Socorro ISD sports team(s) indicated above. The terms hereof shall serve as a release and assumption of risk for my heirs, estate, executor, administrator, assignees, and for all members of my family. Student Signature: Date: Parent Signature: Date:

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5 SOCORRO INDEPENDENT SCHOOL DISTRICT Department of Athletics PARENTAL INFORMATION AND CONSENT FORM WHAT IS A CONCUSSION? A concussion is an injury to the brain. It is caused by a bump, blow, or jolt to either the head or the body that causes the brain to move rapidly within the skull. The resulting injury to the brain changes how the brain functions in a normal manner. The signs and symptoms of a concussion can show up immediately after the injury or may not appear for hours or days after the injury. Concussions can have serious long-term health effects, and even a seemingly mild injury can be serious. A major concern with any concussion is returning to play too soon. Having a second concussion before healing can take place from the initial or previous concussion can lead to serious and potentially fatal health conditions. WHAT ARE THE SYMPTOMS? Signs and symptoms of a concussion are typically noticed right after the injury, but some might not be recognized until days after the injury. Common symptoms include: headache, dizziness, amnesia, fatigue, confusion, mood changes, depression, poor vision, sensitivity to light or noise, lethargy, poor attention or concentration, sleep disturbances and aggression. The individual may or may not have lost consciousness. WHAT SHOULD BE DONE IF A CONCUSSION IS SUSPECTED? 1. Immediately remove the student from practice or game 2. Seek medical attention right away 3. As per Texas State Law, do not allow the student to return to play until proper medical clearance and return to play guidelines have been followed. The permission for return to play will come from the appropriate health care professional. If you have any questions concerning concussions or the return to play policy, you may contact the athletic administrator at your school. WHAT SHOULD THE ATHLETE KNOW ABOUT PLAYING WITH A CONCUSSION? Teach athletes it s not smart to play with a concussion. Rest is the key after a concussion. Occasionally athletes, parents, school staff and/or league officials wrongly believe that it shows strength and courage to play injured. Discourage others from pressuring injured athletes to play. Don t let your athlete convince you that they re just fine. WHAT ARE THE RISKS OF RETURNING TO ACTIVITY TOO SOON AFTER SUSTAINING A CONCUSSION? Prevent long-term problems. If an athlete has a concussion, their brain needs time to heal. Don t let them return to play the day of the injury and until a health care professional says they are symptom-free and it s OK to return to play. A repeat concussion that occurs before the brain recovers from the first usually within a short time period (hours, days, weeks) can slow recovery or increase the chances for long-term problems. WHAT CAN HAPPEN IF MY CHILD KEEPS ON PLAYING WITH A CONCUSSION? Athletes with the signs and symptoms of a concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that adolescent or teenage athletes will often under report symptoms of injuries. And concussions are no different. As a result, education of administrators, coaches, parents and students is the key for student-athlete s safety. Athlete s Name (Please print): ID #: Athlete s Signature: Parent or Guardian s Name (Please print): Date: Parent or Guardian s Signature:

6 SOCORRO INDEPENDENT SCHOOL DISTRICT Department of Athletics RETURN TO PLAY GUIDELINES FOR PARENTS TEACH IT S NOT SMART TO PLAY WITH A CONCUSSION. Rest is the key after a concussion. Occasionally athletes, parents, school staff and/or league officials wrongly believe that it shows strength and courage to play injured. Discourage others from pressuring injured athletes to play. Don t let your athlete convince you that they re just fine. PREVENT LONG-TERM PROBLEMS. If an athlete has a concussion, their brain needs time to heal. Don t let them return to play the day of the injury and until a health care professional says they are symptom-free and it s OK to return to play. A repeat concussion that occurs before the brain recovers from the first usually within a short time period (hours, days, weeks) can slow recovery or increase the chances for long-term problems. Socorro ISD has developed a protocol for managing concussions. This policy includes a multidiscipline approach involving athletic trainer clearance, physician referral and clearance, and successful completion of activity progressions related to their sport. The following is an outline of this procedure. You son/daughter must pass all of these tests in order to return to sport activity after having a concussion. 1. All athletes who sustain a head injury are required to be evaluated by their primary care physician. They must have a normal physical and neurological exam prior to being permitted to progress activity. This includes athletes who were initially referred to an emergency department. 2. The student will be monitored daily at school by the coach and athletic trainer. His/her teachers will be notified of the injury and what to expect. Accommodations may need to be given according to physician recommendations and observations. 3. The student must be asymptomatic at rest and exertion. 4. Once cleared to begin activity, the student will start a progressive step-by-step procedure outlined in the SISD Concussion Management Policy. The progressions will advance at the rate of one step per day as long as no symptoms become present. The progressions are as follows: Phase 1 1. No activity for a minimum of 7 days regardless of Licensed Physician release. 2. Athlete must be symptom free with physician clearance before starting return-to-play protocol. Phase 2 1. Day 1 - Light aerobic exercise 5 10 minutes on exercise bike or light jogging with no resistance training 2. Day 2 - Moderate Aerobic activity and Resistance training min. running in the gym or on the field with no protective equipment, 20 min. of resistance training may include push-ups and sit ups, No weight lifting. 3. Day 3 - Sports Specific drills. Cutting, sprinting, etc. No uniform or protective equipment 4. Day 4 - Return to Full Controlled Practice 5. Day 5 - Return to full activity. Once the athlete has completed phase 1 2. *Note Athlete progression continues as long as the athlete is asymptomatic at current level. If the athlete experiences any post concussion symptoms, the athlete must wait until they are symptom free for 24 hours and start the progression again at the last symptom free step. If athletes experiences symptoms three times during the return-to-play protocol, they must be re-evaluated by a physician.* Phase 3 Licensed Athletic Trainer and/or Middle School Nurse Clearance

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