Home of the Blue Jays and Lady Jays

Dear Blue Jay Parent/Guardian, The Needville ISD Athletic Department arranged to provide physicals for our student-athletes on Tuesday, May 7th in the Main Gym at Needville High School from 4:30-7:30 PM. High school students/ incoming freshmen, please arrive between 5:00pm-6:00pm, Incoming 6th-8th graders please arrive between 6:00pm-7:30pm to allow crowds to move through and reduce your waiting time. If you have siblings that are at both schools you can bring them at the same time. Licensed physicians associated with Memorial Hermann Sugar Land and Memorial Hermann Sports Medicine and directed toward identifying any medical conditions that might affect a student’s health during athletic participation will perform these physicals. The cost of each physical will be $1500 cash. Physicals are provided on campus merely as a convenience for your child; however, you are welcome to obtain your child’s physical from the physician of your choice. Physicals for the 2018-2019 school year must be completed and turned in prior to the student’s participation with any athletic team. For those that are not in activities that start before the first day of school, physical packets must be turned in by the first week of school. Students will not receive any athletic equipment/uniforms until all physical packet forms have been signed and turned in and checked off by the Athletic Trainer. Students that do not turn in their physical prior to the deadline will be removed from athletics and assigned to a regular P.E. course. Needville ISD requires annual physical examinations for incoming 6th graders in pre-athletics and students in grades 7-12 who participate in athletics. A completed physical and all associated forms required by the UIL (for grades 7-12) must be on file with the school before any student may participate in athletic class periods or participate with any athletic team. The UIL requires the athletic physical to be completed on the attached UIL form, which can also be downloaded at: http://www.uiltexas.org/files/athletics/forms/PrePhysForm18-19.pdf Remember to bring your completed physical packet, with all parent signatures, along with $1500 cash on Tuesday, May 7th, if you plan to receive a physical with NISD. Upon completion of the examination, all forms will be kept on file at your child’s respective campus. Physicals are good for one year from date of receipt; forms required by the UIL are due prior to participation every school year. Please submit all completed forms to the athletic training room prior to the first day of tryout/practice. Thank you and please feel free to contact us if you have any questions Cale M. Cosper, LAT Casey R. Nichols, LAT Head Athletic Trainer Assistant Athletic Trainer Needville ISD Needville ISD 979-793-4308 x1997 979-793-4308 x1997 cosperc@needvilleisd.com nicholsc@needvilleisd.com

Athletic Training Room Needville High School P.O. Box 412 Needville, Texas 77461

Cale M. Cosper, LAT Casey R. Nichols, LAT

Home of the Blue Jays and Lady Jays

Name_________________________________________________________ Grade for 2019-2020 : 6th / 7th / 8th /Fr / So / Jr / Sr Student ID# Birthdate_______________ Student Cell Phone Athlete’s Home Address_______________________________________________________________________________________ City______________________________________________ State______________________ Zip Code______________________ Parent/Guardian: (father)_____________________________________ (mother)________________________________________ Home Phone__________________________________________________Home Phone____________________________________ Work Phone__________________________________________________Work Phone____________________________________ Cell Phone____________________________________________________Cell Phone Parent’s E-mail Additional Emergency Contact _______________________________Phone_____________________ relation________________ PRIVATE (PRIMARY) INSURANCE Co. Name____________________________________________ Pre-authorization phone # ________________________________ Type of policy: Indemnity Plan PPO EPO HMO Medicaid Insurance Company Address___________________________________________________________________________________ Name of Insured_______________________________________________________ Group#______________________________Policy#_____________________________Other#______________________________ My son / daughter is covered by the above insurance policy. ___________Yes______________No

Known Allergies (drug, food, insect, etc.)_________________________________________________________________________ Special Medical Problems _____________________________________________________________________________________ Medications (inhaler, insulin etc…)_____________________________________________________________________________

Please check all OTC medications you allow to be given to your student by the Athletic Trainer/ coach: Tylenol (acaetaminophen) Advil (Ibuprofen) Aleve (Napoxen Sodium) Benadryl (diphenhydramine HCL) Immodium Tums Cough Drops/Throat spray Heat Guard/Electrolytes Hydrocortizone ointment NO MEDICATIONS ALLOWED OTC Medication Permit I hereby hold the athletic trainer and NISD harmless in the administration of non-prescription (OTC) medications to the above listed student. I understand that the medication will be provided in single dose only. No medications will be given for long-term use (longer than 5 consecutive days). The school district and athletic trainer accept no responsibility for OTC medications that are defective, either by their design or dosage recommendations or that are misused by the athlete. The misuse of medications will result in loss of medication privileges. Parent/Guardian Signature_______________________________________________________________Date_________________

Parent / Guardian Consent to Treatment of Student-Athlete

I,_____________________________________, the undersigned parent / guardian of _______________________________________________, Name of Student (please print)

a minor, do hereby authorize the Needville ISD athletic trainer, coach and/or school representative on my behalf to consent to any medical treatment deemed necessary by any licensed physician and/or licensed medical provider in the event of illness or injury to the above named minor.

This consent to treat is intended to cover any illness or injury sustained while participating in any school athletic competition or practice, on or off campus, and while traveling to and from the event.

I understand that this authorization is given in advance of any specific diagnosis and resulting treatment or hospital care required. This authorization is given to provide the aforesaid agent(s) the power to give specific consent to all such diagnosis and resulting treatment or hospital care deemed advisable by the aforementioned licensed physician and/or licensed medical provider in the event the parents/guardians or emergency contacts are not able to be reached. I hereby authorize any hospital, which has provided treatment to the above named student to surrender custody of that student to the athletic trainer or school representative upon completion of treatment.

These authorizations shall remain effective until the end of the current above noted school year.

___________________________________________________________________________ _____________________________ Student / Athlete Signature Date

_______________________________________________________________ ________________________ Parent / Guardian Signature Date

Needville ISD Athlete Emergency Information 2019-20209 Please Print (Except for Signatures)

SIGNATURE FORM

Name of Student (print)___________________________________ Grade____ Date of Birth__________

Parent or Guardian (print)________________________________________________________________

Concussion Acknowledgement Form Signature:

I have read and understand the Concussion Acknowledgment Form provided to me on the NISD High School website and will follow proper protocols for a concussion.

____________________________________________________________ ________________ Parent or Guardian Signature Date

____________________________________________________________ _________________ Student Signature Date

Sudden Cardiac Arrest (SCA) Awareness Form Signature:

I have read and understand the SCA Awareness Form provided to me n the NISD High School website.

____________________________________________________________ ________________ Parent or Guardian Signature Date

____________________________________________________________ _________________ Student Signature Date

GENERAL INFORMATION & GENERAL ELIGIBILITY RULES FORM SIGNATURE:

I understand that failure to provide accurate and truthful information on UIL forms could be subject to the student in question to penalties determined by the UIL.

I have read the regulations cited in the General Information and General Eligibility Rules provided on the NISD High School website and agree to follow the rules.

____________________________________________________________ ________________ Parent or Guardian Signature Date

____________________________________________________________ _________________ Student Signature Date

To the Parent: Check any activity in which this student is allowed to participate.

ACKNOWLEDGEMENT OF RULES

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.

Furthermore, as a condition of participation and for the purpose of ensuring compliance with University Interscholastic League (UIL) rules, I consent to the disclosure of personally identifiable information, including information that may be subject to the Family Educational Rights and Privacy Act (FERPA), regarding the above named student between and among the following: the high school or middle school where the student currently attends or has attended; any school the student transfers to; the relevant District Executive Committee and the UIL. I further understand that all information relevant to the student’s UIL eligibility and compliance with other UIL rules may be discussed and considered in a public forum. I acknowledge that revocation of this consent must be in writing and delivered to the student’s school and the UIL.

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 judgement 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 www.uiltexas.org/files/athletics/manuals/parent-information-manual.pdf.

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.

Baseball Football TennisBasketball Golf Track & Field Cross Country Soccer

Softball Power-lifting Team Tennis Volleyball

Wrestling

Attention School Authorities: This form must be signed yearly by both the student and parent/guardian and be on file at your school before the student may participate in any practice session, scrimmage, or contest. A copy of the student’s medical history and physical examination form signed by a physician or medical history form signed by a parent must also be on file at your school.

Student’s Name Date of Birth Current School

Signature of parent or guardian __________________________ __________date_____________

Dance/Cheer Band/Color Guard/ROTC Other: __________________

University Interscholastic League

School Year (to be completed annually) ______________

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 As a prerequisite to participation in UIL athletic activities, I agree that I will not use anabolic steroids as defined in the UIL Anabolic Steroid Testing Program Protocol. I have read this form and understand that I may be asked to submit to testing for the presence of anabolic steroids in my body, and I do hereby agree to submit to such testing and analysis by a certified laboratory. I further understand and agree that the results of the steroid testing may be provided to certain individuals in my high school as specified in the UIL Anabolic Steroid Testing Program Protocol which is available on the UIL website at www.uiltexas.org. I understand and agree that the results of steroid testing will be held confidential to the extent required by law. I understand that failure to provide accurate and truthful information could subject me to penalties as determined by UIL. Student Name (Print): ___________________________________________ Grade (9-12) _______ Student Signature: _____________________________ Date: ___________ PARENT/GUARDIAN CERTIFICATION AND ACKNOWLEDGEMENT As a prerequisite to participation by my student in UIL athletic activities, I certify and acknowledge that I have read this form and understand that my student must refrain from anabolic steroid use and may be asked to submit to testing for the presence of anabolic steroids in his/her body. I do hereby agree to submit my child to such testing and analysis by a certified laboratory. I further understand and agree that the results of the steroid testing may be provided to certain individuals in my student’s high school as specified in the UIL Anabolic Steroid Testing Program Protocol which is available on the UIL website at www.uiltexas.org. I understand and agree that the results of steroid testing will be held confidential to the extent required by law. I understand that failure to provide accurate and truthful information could subject my student to penalties as determined by UIL. Name (Print): ___________________________________________ Signature: _____________________________ Date: ___________ Relationship to student: ___________________________________

Blue Jay Athletic Booster Club

What are we? The Needville Blue Jay Athletic Booster Club is a nonprofit organization established to support the NISD Athletic program and its student-athletes. What we do: Funds are raised throughout the year with various activities such as the Blue Jay Spirit Store, concession stand sales, and fundraisers. Proceeds from these activities are then used to assist and enhance NISD Athletics with items such as but not limited to: equipment, supplies, and uniforms. We also award scholarships each year to eligible graduating athletes. By providing these items the Blue Jay Booster Club minimizes expenses associated with the athletic program that may not be available otherwise.

• Membership o Option 1: Annual Membership (must be renewed every year to be eligible for

scholarship) Cost: $50/annually o Option 2: Lifetime Membership (one-time fee, covers all children;

Cost: $150/once (includes plaque & yearly name recognition in football program)

NOTE: Both options have a deadline of March 15th of the enrolled school year.

• Parent Participation: o Help with: Blue Jay Spirit Store, concession duty, hospitality, fundraising, etc. o Enhances athletes’ scholarship consideration upon graduation

• Scholarship Eligibility o Student athlete must have participated in athletics during all 4 years of high

school o Parent/guardian of student athlete must be member for the same 4 years

• For More Information o Contact a Board Member; for list of Board Members, visit:

http://www.needvilleisd.com/default.aspx?name=Booster o Attend a Meeting: Meetings held every first Monday of the Month; 7pm at

NHS LGI Room Thank you for your time, support, and commitment to our program; we hope to hear from you soon! Needville Blue Jay Athletic Booster Club

Needville Blue Jay Athletic Booster Club

2019-2020 Membership Application Form

Name: __________________________________________________________________________

Business Name: __________________________________________________________________

Address: ________________________________________________________________________

________________________________________________________________________

Cell Phone: ________________________ Email: _____________________________________

Children’s names and grade (only one application needed for all children listed):

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Check your membership choice:

_____ $50 Annual Membership

_____ $150 Lifetime Blue Jay Membership (single payment, includes plaque)

Parent Signature: _______________________________ Date: _____________

**Your signature indicates that you acknowledge the information on this page will be shared with the Needville Blue Jay Athletic Booster Club for reasons of volunteer work, fundraising, concession, hospitality, and/or other athletic related events.

Please make checks payable to: Blue Jay Booster Club **all NSF checks are subject to a $25 handling fee**

Please staple or tape check to this form and return to either:

Mike Giles, Athletic Director Jeanna Valenta, Membership Coordinator Needville High School PO BOX 892 P.O. Box 412 Needville, Texas 77461 Needville, Texas 77461

Date Rec'd: _____________ Amount Rec'd: _____________

Payment Type: __________

Ordered: __________ Delivered: __________

Plaque: Y or N

Data Entry: __________

For Board Use Only: