Cleburne ISD 2014-2015 Athletic Participation Packet

Cleburne ISD 2014-2015 Athletic Participation Packet Participation

Please check any activity in which this student athlete is allow to participate.

□ Baseball □ Football □ Softball □ Tennis □ Basketball □ Powerlifting □ Swimming & Diving

□ Soccer □ Golf □ Volleyball □ Team Tennis □ Cross Country □ Track and Field

CLEBURNE ISD DRUG/ALCOHOL SCREENING TEST

PARENT/GUARDIAN – I understand the Cleburne ISD policy regarding substance abuse and participation in CISD sponsored extracurricular activities. I understand that it is the practice of CISD to conduct drug and alcohol testing for the purpose of carrying out this policy and before allowing students to participate in extracurricular activities.

I understand that the urine sample my child gives will be tested for drugs and/or alcohol. I understand the giving of a urine sample, when requested by CISD is a condition of my child’s continued participation in extracurricular activities. I also understand that if my child’s urine sample reveals an unexplained presence of a drug or alcohol that CISD will take disciplinary action against her/him up to and including termination from participation in extracurricular activities. Medications that are legally prescribed by a physician may be exempt. I understand that failure to provide a urine sample (physically or verbally), the student’s behavior at the testing site is disruptive, or providing a faulty or cold sample upon request will result in the student’s sample results to be positive. Based on my understanding of the above information, I hereby authorize 24/7 Mobile Drug and Alcohol Testing to collect a urine sample from my child for the sole purpose of testing for the presence of drugs and alcohol.

I further authorize the specified employees and administrators of 24/7 Mobile Drug and Alcohol Testing and CISD to communicate my child’s test results both orally and in writing to the CISD High School Principal and/or Athletic Director. I also authorize specific employees and administrators of 24/7 Mobile Drug and Alcohol Testing and CISD to have continued access to my child’s urine sample/test results for the purpose of further analysis or study that may be necessary and those results will be communicated to me prior to any CISD administrative proceedings or disciplinary actions. I understand this information will not become part of my child’s medical record. I also understand that there is no patient/physician relationship established by the collection of urine by 24/7 Mobile Drug and Alcohol Testing and that no privilege of confidentiality will be associated with these test results.

I HEREBY RELEASE AND HOLD HARMLESS 24/7 MOBILE DRUG AND ALCOHOL TESTING, IT’S TRUSTEES, OFFICERS, EMPLOYEES, AGENTS, REPRESENTATIVES, AND MEDICAL STAFF FROM ANY AND ALL LIABILITY , CLAIMS, DAMAGES, AND COSTS THAT MAY ARISE AS A RESULT OF ANY ACTION TAKEN OR UNFAVORABLE OUTCOME THAT OCCURS AS A RESULT OF A DRUG/ALCOHOL TEST.

MY CHILD HAS TAKEN THE FOLLOWING MEDICATIONS, BOTH PRECRIPTION AND OVER-THE-COUNTER SUBSTANCES, WITHIN THE PAST 2 WEEKS. (PLEASE LIST).

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Updated Spring 2014 Turn this form in to Head Coach or Athletic Trainer 1 Cleburne ISD 2014-2015 Athletic Participation Packet ATHLETE’S FULL NAME: ______Date of Birth:______Age: ______ID#:______

Home Address: ______City: ______Zip: ______

Home Phone: ______Sports: ______

Campus 2014-2015: ______GRADE 2014-2015: ______

CONTACT INFORMATION

PARENT/GUARDIAN NAME: ______Relation: ______

Home Phone: ______Work Phone: ______Cell Phone: ______

PARENT/GUARDIAN NAME: ______Relation: ______

ALTERNATE EMERGENCY CONTACT: ______Relation: ______

EMERGENCY MEDICAL INFORMATION

Allergies (medicine, food, insects, etc.): ______

Current and/or Routine Medication Taken: ______

(Check No or Yes) Glasses: □No □Yes Contacts: □No □Yes Asthma: □No □Yes Inhaler: □No □Yes Epi-Pen: □No □Yes

Diabetes: □No □Yes □Type 1 □Type 2 Heart Condition: □No □Yes List All: ______

Other medical concerns that should be noted: ______

PARENT/GUARDIAN’S PERMIT 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. 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 & STUDENT ACKNOWLEDGEMENT  I understand this packet must be filled out COMPLETELY.  I agree to follow the rules and regulations with the Athletic Participation Packet.  If between this date and the beginning of athletic practice/competition, any illness or injury should occur that may limit this student’s participation, I agree to notify the school authorities of such illness or injury.  I understand that all these forms are available online for me to review on the Cleburne ISD website.  I understand that all information contrained in this packet will only be seen by the Licensed Athletic Trainer, coach, school administrator, physician, parent/guardian, or student.

 By signing below I acknowledge that I have read and understand the contents of this whole and complete 10 page packet that includes the following items: ● Contact Information ● UIL Pre-Participation Physical Evaluation ● UIL Steroid Testing Information & Acknowledgement ● UIL Concussion Acknowledgement ● CISD Athletic Injury Procedure ● CISD Drug & Alcohol Screening ● UIL Sudden Cardiac Arrest ● CISD Insurance Policy Information ● UIL Acknowledgement of Rules

Updated Spring 2014 Turn this form in to Head Coach or Athletic Trainer 2