The Katy ISD Athletic Department would like to thank you for taking the time to complete the U1L and

Transcription

1 Dear Parents, The Katy ISD Athletic Department would like to thank you for taking the time to complete the U1L and Katy ISD required forms to participate in the athletic program. All student athletes 7-12th grade are required to fill out and submit these forms online prior to each school year. You may begin submitting forms for the school year on Monday, pril 23rd. Any forms submitted prior to April 23rd, will ha e to be resubmitted. The link to the online paperwork is: The only required form that cannot be done electronically is the annual physical and medical history. Parents will be able to print a physical and medical history during the electronic session. The physical/medical history must be completed by a parent and a physician. The physical must be dated after May 1, 2018 to be valid for the school year. If you encounter any problems trying to submit your forms online, please contact the athletic trainer at the high school of your attendance zone. KHS Justin Landers Russell Sadberry MCHS Chris Whitten Emily Borup MRHS Javet Forges Alex Song OTHS Dallas Allmon Claire Mifsud THS Anjanette Koenig Daniel Young CRHS Bennett Johnson Amy Dietz SLHS Sean ay Liz Wagner PHS Rudy Lazar Laura Wilcox

2 Katy Independent School District Sponsored Physical Examinations Ph sical examinations will only be given to KISD student athletes participating in UIL activities gra es The UIL physical form will be the only physical form accepted. Although KISD recommends the use of your family doctor for t e physical examin tion, the following mass screenings are available as an econ mical convenience for its patrons. KISD sponsored physical examinations will be performed by the Medical Colleges of Texas at a nominal fee of $25. Date Facility Location Athletes 5:3Qpm- MCHS 9th Grade Gy : Tuesday, May 1, :15pm Wednesday, May 2, 2018 THS Gym 4 5:30-6:15pm ; Thursday, May 3, 2018 SLHS Competition: Gym :15pm Monday, May 7, 2018 BDJH Competition Gym 5:30-6:15 m : uesday, May 8, 2018 MRHS Competition Gym 5:30-6:15pm Wednesday, May 9, 2018 WCJH Competition Gym 5:30-6:15pm i Monday, May 14, 2018 PHS Competition Gym 5:30-6:15pm ; Tuesday, May 15, 2018 OTHS Competition Gym 5:30-6:15pm : Wednesday, May 16, 2018 : KHS Competition Gym 5:30-6:15pm Thursday, May 17, 2018 ; CRHS Competition Gym 5:30-6:15pm Tuesday, July 24, 2018 : OTHS Competition Gym 6:00-6:45pm Wednesday, July 25, 2018 ; MRHS Competition Gym 6:O0-6: 5pm i Thursday, July 26, 2018 KHS Competition Gym 6:00-6:45pm : Monday, July 30, 2018 THS Gym 4 6:00-6:45pm Tuesday, July 31, 2018 ; MCHS 9th Grade Gym 6:00-6:45pm Wednes ay, August 1,2018 PHS Competition Gym :45pm Tuesday, August 7, 2018 ; MDJH Competition Gym 6:00-6:45pm Thursday, August 9, 2018 ; SLHS Competition Gym 6:00-6:45pm Monday, August 13, 2018 : CRHS Competition Gym 6:O0-6:45pm Wednesday, August 15, 2018 Merrell Center Sout Lobby 5:30-6:15pm Thursday,, August 16, 2018 errell Center South Lobby 5:30-6:15pm! Friday, August 17, 2018 Merrell Center South Lobby 5:30-6:15pm

3 PREPARTICIPATION PHYSICAL EVALUATION - MEDICAL HISTORY 2017 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 develo ed any condition which would make it hazardous to articipate in an athletic event. Student's Name: (print) Sex Age Date of Birth A dress Grade Personal Physician In case of emergency, contact: School Name Relationship Phone(H) (W) Explain Yes answers in the box below**. Circle questions you don t know the answers to. Phone Phone 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 ore 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 ember or relative died of heart problems or of sudden unexpected death before age 50? Has any fa ily member been diagnosed with enlar ed heart, (dilated cardiomyo athy), hypertrophic cardiomyopathy, long QT syndrome or other ion channelpathy (Bruga a syndrome, etc), Marfan's syndrome, or abnormal heart rhyth? Have you had a severe viral infection (for example, yocarditis or mononucleosis) ithin 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 memor? 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 nu bness or tingling in your arms, hands, legs or feet? Have you ever had a stinger, bu er, 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 ills 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 0 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 e ui ment or devices that aren't ually used for your sport or position (fo example, knee brace, special neck roll, foot orthotics, retainer on your teeth, hearing aid)? Have you ever had a sprain, strain, or swelling after injur? Have you broken Or fractured any bones or dislocated any joints? Have you had any other problems ith pain or swelling in muscles, tendons, bones, or joints? If yes, check appropriate box and explain below: Head L Elbow Hip Neck C Forearm Thigh Knee Back C Wrist Chest C Hand Shoulder C Finger Upper Arm E3 Foot Do you want to weigh more or less than you do now? o you feel stressed out? Shin/Calf l~l Ankle 18. Have you ever been dia nosed 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? Yes No How uch time do you usually have from the start of one period to the start of another? How many eriods have you had in the last year? What was the longest time between periods in the last year? Males Only 20, Do you have two testicles? 21. Do you have any testicular swelling or masses? An In ividual answering In the afllrmative to any question rel ting to a possible cardiov scul r he lth Issue (question three above), as identifi d on the form, should be restricted from further participation until the Individual is examined an cleared b a physician, hysician assistant, chiropractor, or nurse practitioner. ' ' **EXPLAIN YES ANSWERS IN THE BOX BELO (attach another sheet if necessary): It is understood that even thou h protective equipment is wo b the athlete, whenever needed, t e possibility of an accident still remains. Neither the University Interscholastic League nor the school assumes any res onsibility in case an accident occurs. If, in the judgment of any representative of the school, the above student should need im ediate care and treatment as a result of any injur or sickness, I do hereby request, authorize, and consent to such cate and treatment as may be given said student by an physician, athletic trainer, nurse or school representative. I o 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 sai student. If, between this date and the beginning of athletic competition, any illness or injury should occur that may li it this student's participation, I agree to notify the school authorities of such illness or injury. I hereb state that, to the best of my kno ledge, m answer to the above questions are complete and correct. Failure to rovide truthful responses coul subject the student in uestion to penalt es determined b the UIL Student Signature: Parent/Guardian Signature: Date: Any Yes ans er to ue tions 1,2,3,4,5, or 6 equire further medical evalua ion which may inclu e a h sical examination. ritten clearance from a h sician, physician assistant, chiro acto, or nurse practitioner is requi ed before an artici ation Id UIL ractices, games or matches. THIS FORM MUST BE ON FILE PRIOR TO PARTICIPATIONINANYPRACTICE, SCRIM AGE OR CO TESTBEFORE,DURING OR FTERSCHOOL. For School U e Only: This Medical History Form was reviewed by: Printed Name Date Signature

4 PREPARTICIPATION PHYSICAL EVALUATION - PHYSICAL EXAMINATION Student's Name Sex Age Date of Birth Height Weight % Body fat (optional) Pulse BP / ( / J ) brachial blood pressure while sitting Vision: R 20/ L 20/ Corrected: Q: Y N Pu ils: Q Equal Q: Unequal s a minimum requirement, t is Physical E amination For must he completed prior to junior high athletic participation and again rior to first and third years of high school athletic partici ation. It must be completed if there are yes answers to specific questions On the stu ent's MEDICAL HISTORY FORM on the reverse side. * Local district policy may require an annual physical exam. 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, peetus: excayatum, joint hypermpbility, scoliosis) MUSCULOSKELETAL Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hand Hip/Thigh Knee Leg/Ankle Foot NORMAL AB ORMAL FI DINGS INITIALS* station-based examination only CLEARANCE Cleared Cleared after completing ovaluation/rehabilitation for: Not cleared for: Reason: ecommendations: The following information must he filled in and signed by either a Physician, a Ph ician As i tant licensed by a State Board of hysician As i tant Examiners, a Registered N rse recognized as an Advanced Practice N rse by the Board of Nurse Examiners, or a Doctor' of Chiropractic. Examination for s signed by any other health care practitioner, will not be accepted. Name (prinl/type) Date of Examination: Address:...: Phone Number: Signature:' Must be completed before a student partici ates in any practice, before, during or after school, (both in-season and out-of-season) or games/matches.

5 REQUIRED ATHLETIC FORMS FOR TRYING OUT FOR SPORTS All students trying out for any sport are required to have the completed KISD Athletic Information Packet forms on file in order to try out. Required forms included in this packet are: 1. UIL Pre-Participation Physical Evaluation (Medical history and Pre-Participation Physical Evaluation-Physical Exam)- with student and parent signature at the bottom and the physical completed by a physician clearing the student for participation dated and signed by the physician. ***Phvsical must be dated on or after May 1,2018.*** This form must be a paper copy of the KISD form turned in to coaches. 2. The followin forms are to be submitted electronicall throu h Rank One Soort using the link: Navigate to Electronic Forms under the Parents Tab. Click Electronic Participation Forms > UIL Forms Signature Page (There are 4 forms within this form.) > Handbook Acknowledgement Form > Consent To Treat > Bona Fide Residence *AII Online Forms must be filled out electronically, signed by both parent and student and submitted on the computer. Paper copies of medical history and physical exam are available in the coaches office. Forms are also available on the Rank One Sport website. **lf you have moved into the Beck attendance zone from another Katy ISD school, let Coach Corn know so your information can be moved over from your previous school. ***lf the website is not recognizing your child s ID number. Please the following to kristiicorn@katvisd.ora and I will add your child to the system. Student s first and last name ID number Grade Birthday Address