Spring Independent School Districtuil Athletic Participation Form (Page 3 of 4) in pdf

CONCUSSION ACKNOWLEDGEMENT FORM

Student Name:

Definition of Concussion - means a complex pathophysiological process affecting 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 fit properly and be inspected on a regular basis.

Signs and Symptoms of Concussion – The 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 vision, 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). The 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, neuropsychologist or a physician’s assistant. The COT is charged with developing

the Return to Play protocol based on peer reviewed scientific evidence.

Treatment of Concussion - The student-athlete shall be removed from practice or competition immediately if suspected to have sustained a concussion. Every student-

athlete suspected of sustaining a concussion shall be seen by a physician before they may return to athletic participation. The 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:

the student has been evaluated, using established medical protocols based on peer-reviewed scientific evidence, by a treating physician chosen by the student or the

student ’s parent or guardian or another person with legal authority to make medical decisions for the student;

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;

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

the student and the student ’s parent or guardian or another person with legal authority to make medical decisions for the student:

have acknowledged that the student has completed the requirements of the return-to-play protocol necessary for the student to return to play;

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

have signed a consent form indicating that the person signing:

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 recommendations of the treating physician; and

iv)

understands the immunity provisions under Section 38.159.

__________________________________

___________________________

_____________

PARENT/GUARDIAN SIGNATURE

STUDENT’S SIGNATURE

DATE

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

PARENT/GUARDIAN CERTIFICATION AND ACKNOWLEDGEMENT

As a prerequisite to participation by my student in UIL athletic activities, I certify and

As a prerequisite to participation in UIL athletic activities, I agree that I will not use anabolic

acknowledge that I have read this form and understand that my student must refrain from

steroids as defined in the UIL Anabolic Steroid Testing Program Protocol. I have read this form

anabolic steroid use and may be asked to submit to testing for the presence of anabolic steroids

and understand that I

in his/her body. I do hereby agree to submit my child to such testing and analysis by a certified

may be asked to submit to testing for the presence of anabolic steroids in my body, and I do

laboratory. I further understand and agree that the results of the steroid testing may be provided

hereby agree to submit to such testing and analysis by a certified laboratory. I further understand

to certain individuals in my student’s high school as specified in the UIL Anabolic Steroid

and agree that the results of the steroid testing may be provided to certain individuals in my high

Testing Program Protocol which is available on the UIL website at I

school as specified in the UIL Anabolic Steroid Testing Program Protocol which is available on

understand and agree that the results of steroid testing will be held confidential to the extent

the UIL website at I understand and agree that the results of steroid testing

required by law. I understand that failure to provide accurate and truthful information could

will be held confidential to the extent required by law. I understand that failure to provide

subject my student to penalties as determined by UIL.

accurate and truthful information could subject me to penalties as determined by UIL.

Name (Print): ___________________________________________

Student Name (Print): ________________________ Grade (9-12) _____

Parent Signature:

_____________________________ Date: _______

Student Signature

____________________________ Date: ________

Relationship to student: ___________________________________

Spring Independent School Districtuil Athletic Participation Form Page 3

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