Spring Independent School Districtuil Athletic Participation Form printable pdf download

SPRING INDEPENDENT SCHOOL DISTRICT

UIL ATHLETIC PARTICIPATION FORM

*Please use Blue/Black ink and Print legibly*

Spring ISD Athletics will only accept physicals that are administered and dated no earlier than April 1

of the calendar year that fall sports begin.

School ID #:

Gender: Male / Female

GRADE:

Student’s Name: __________________________________ Address:____________________________________City/Zip:__________________________

Student’s Cell Phone:_______________ Date of Birth:_________ Age:____ LIST CURRENT MEDICATIONS: ______________________________

DRUG ALLERGIES:________________________________ ALLERGIES:_____________

________________________________

CURRENT MEDICAL CONDITIONS: Asthma:

YES

NO /

Diabetes: YES

/ Other:____________________________

SCHOOL:

Dekaney H.S.

Spring H. S.

Westfield H.S.

Bailey M.S.

Bammel M.S.

Claughton M.S .

Duiett M.S.

Roberson M.S.

Twin Creeks M.S.

Wells M.S.

MALE PARENT: ____________________________________________

FEMALE PARENT: __________________________________________

Home Phone: _________________________________________________

Cell Phone: ___________________________________________________

Work Phone: __________________________________________________

E-Mail Address: _______________________________________________

EMERGENCY CONTACT: Please list the emergency contact IN CASE a parent/guardian CANNOT be reached:

Name: ________________________________________________________ Home Phone: _________________________________________________

Pager/Cell Phone: _______________________________________________ Work Phone: __________________________________________________

Relationship: _________________________ Family Physician: _____________________________________ Office Phone: _____________________

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: ______________________________________________________

CHECK HERE IF THIS ATHLETE IS COVERED BY EITHER MEDICAID OR CHIP.

CHECK HERE IF THIS ATHLETE IS NOT COVERED UNDER ANY HEALTH INSURANCE PLAN AT THIS TIME

MEDICAL EXPENSE / INSURANCE: Spring ISD strongly encourages all UIL/extra curricular participants to carry primary health care insurance due to risk of injury.

Primary health care insurance may be purchased through the parent/guardian's employer. Any and all medical bills are the responsibility of the parent/guardian of the injured

student. If you do not have personal insurance for your son/daughter, please consider purchasing extended coverage for them.

MEDICATION PERMISSION -OPTIONAL (Applies to high school student athletes only)

Athletic Trainers, Licensed by the State of Texas (LAT) and employed by Spring ISD, are hereby given my acknowledgment and consent to administer non-prescription over-

the-counter (OTC) medication to my child. OTC medications include, but are not limited to Tylenol, Advil, Aleve, Imodium A-D, Benadryl, Sudafed, Emetrol, Robitussin,

cough drops, electrolytes or generics. I also give consent to administer prescription medication when prescribed by my child's physician and accompanied by the original

prescription label on the medication container.

PARENT/GUARDIAN SIGNATURE:

Date:

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 judgment 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

• Your signature below gives authorization that is necessary for the school district, its licensed athletic trainers, coaches, associated physicians and student insurance personnel to share information

concerning medical diagnosis and treatment for your student.

__________________________________

______________________ _____

_____________

PARENT/GUARDIAN SIGNATURE

STUDENT’S SIGNATURE

DATE