Mckinney Independent School District Uil Physical Exam Form (Page 2 of 4) in pdf

PHYSICALS MUST BE COMPLETED AFTER APRIL 1, 2014

INSURANCE

McKinney I.S.D. (MISD) does provide limited accident insurance coverage for all 7

through 12

grade students who participate in any activity sanctioned by the

University Interscholastic League (UIL). The insurance provided by the school is for activities that are sanctioned by UIL rules and regulations. Any

competition in which the student participates that is NOT under UIL sanction will NOT be covered under school insurance. However, parents must still

assume responsibility for any injury sustained, regardless of any amounts paid by any insurance company. The policy provided by MISD is only intended to serve as

an excess secondary insurance policy and not to cover all expenses incurred. Any injury occurring in, or as a result of, participation in a UIL sanctioned activity

and/or MISD athletic activity, must be reported to the student’s high school athletic trainer and/or coach the day of injury. Treatment must begin within 30 days from

the injury and claims must be filed within 90 days of the injury. It is the responsibility of the parent or guardian to file a claim.

An insurance claim form may

be obtained from an Athletic Trainer or Middle School Coordinator.

STUDENT ATHLETE INJURYAND/OR ILLNESS REPORT

Any student athlete visiting a licensed medical Provider for any illness or injury must obtain a report signed by said Provider containing the following information.



Nature of illness or injury



Treatment of illness or injury including medication, protective gear, etc.



Specific instructions regarding any restrictions from full participation in athletics, (e.g. may participate in non-contact environment, may not

participate at all, etc.)



Date of release that student athlete may participate in athletics with no restrictions; and



The team physician together with a licensed athletic trainer shall have the final decision regarding whether the athlete will participate or play.

This signed report is to be submitted to the athletic trainer upon return to school, prior to any or all participation. A copy of the clearance form must be

obtained by the Sports Medicine Staff and presented to the appropriate coach prior to the activity.

HEAD INJURY POLICY

McKinney ISD student athletes that receive three significant concussions during one calendar year may be restricted from

participation for the remainder of that season. Concussions suffered by a student athlete will be evaluated on a case-by-case basis.

MISD student athletes will be referred to a physician if they present with any concussion symptoms at any time. MISD will follow

its concussion management guidelines in place. A copy of this information is available on the MISD athletic website and from

MISD Athletic Trainers.

The ImPACT (Immediate Post-concussion Assessment and Cognitive Testing) evaluation was created as a screening tool to assist

sports medicine professionals in evaluating athletes after a suspected concussion. ImPACT was not designed to take the place of

regular medical care and should not be used without proper oversight. ImPACT should never be used as a “stand alone” instrument

to make decisions regarding whether an athlete returns to play and the ImPACT results should always be considered within the

context of the overall medical care of the athlete.

By signing below, you give permission for your child to have a baseline ImPACT (Immediate Post-concussion Assessment and

Cognitive Testing) administered prior to participation at MISD. There is no charge for the testing. Further, by signing below, you

authorize MISD to release the ImPACT (Immediate Post-concussion Assessment and Cognitive Testing) results to your child’s

primary care physician, neurologist, treating physician, and/or other designated physician. Your signature also authorizes the

disclosure of information about the treatment of a head injury, if one occurs, to your child’s guidance counselor’s, teachers, and

coaches for the purposes of evaluating the need for temporary academic modifications and restricted athletic activity.

By signing below you acknowledge that you have read and understand the Insurance, Student Injury/Illness Report and Head Injury Policy. You do

hereby agree that your son/daughter will abide by said rules.

Student Signature________________________________________________________________

Date_____________________

Parent/Guardian Signature________________________________________________________

Date_____________________

SAFETY WARNING: MUST BE SIGNED BY EACH FOOTBALL PARTICIPANT AND PARENT

No helmet can prevent all head and neck injuries a player might be exposed to while playing football. DO NOT use helmets to butt, ram or spear an

opposing player. This conduct is a violation of football rules and such use can result in severe head or neck injuries,

paralysis or death to you and possibly injury to your opponent.

I have read and understand the above Safety Warning.

Student Signature________________________________________________________________

Date_____________________

Parent/Guardian Signature________________________________________________________

Date_____________________

Mckinney Independent School District Uil Physical Exam Form Page 2

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