ALVIN INDEPENDENT SCHOOL DISTRICTAPPLICATION FOR ATHLETIC PARTICIPATION

Must be completed before a student participates in any practice, athletic period (both in-season and out-of-season) or games/matches.

Athlete's Name(pleasePrint) ------".-Las--:t-,-(p~rin..."t),.-----------RFIIS=::t:-7:(p='rin""t).--------Mii:7·;Tddlr.:e"'(pri:-:;·"'nt).,..--------

Mailing Address City State. Zip _

Sex: M F Birthday / /, _ Phone Number ('-__ ...J) _ 2011112 Grade _

School: AHS MHS HJH MJH AJH FJH NRJH ASSETS

Emergency Contact Information Primary Contact _

Father/Guardian Information Mother Guardian Information RelativelFriend InformationName: _ Name: _ Name: _

Home Phone: _ Home Phone: _ Home Phone: _

Cell Phone: Cell Phone: Cell Phone:

Work Phone: _ Work Phones, -------------- _ Work Phone: _

Email: Email: _ Relationship: -------------

Insurance Information

Is There Primary Insurance Coverage For The Student Athlete? Yes _ No, I do not have insurance _

(If Yes) Name of Insured: _ Group # _

Name of Insurance Company: Policy # _

Insurance Company Phone: (,-__ ) _

Type of Policy: HMO _ PPO Other (Explain) _

Alvin Independent School DistrictParent Authorization To Consent To Treatment Of Student Athlete

(I) (We), the undersigned parent(s) of , a minor, do hearby authorize Alvin Independent SchoolDistrict athletic staff as agent( s) for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis ortreatment, and hospital care which is deemed advisable by, and is to be rendered under the general or supervision of, any licensedphysician/surgeon, whether such diagnosis or treatment is rendered at the office of said physician/surgeon or at a hospital.

It is understood that this authorization is given in advance of any specific diagnosis treatment or hospital care being required but is givento provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment orhospital care which aforementioned physician/surgeon in the exercise ofhislher best judgement may deem advisable, (I) hereby authorize anyhospital which has provided treatment to the above-named minor to surrender physical custody of such minor to (my)( our) above-namedagent(s) upon the completion of treatment.

I also understand that the release of medical information might be necessary for proper treatment to be given by the any of the abovenamed agents. I do hereby authorize the release of any information protected by Health Information Portability and Accountability Act(HIPPA) or the Family Educational Rights and Privacy Act of 1974 (FERPA) to the above mentioned agents including Alvin IndependentSchool District's Medical Staff.

Parent/Guardian Signature: -----Date: __ ---'1 1 _

Student! Athlete Signature: Date: __ ----'I 1 _

Physical Revised 11

GENERAL INFORMATIONSchool coaches may not:'Transport, register, or instruct students in grades 7-12 from their attendance zone in non- school baseball, basketball, football, soccer, softball, or volleyball camps(exception: See Section 1209 of the Constitution and Contest Rules). 'Give any instruction or schedule any practice for an individual or a team during the off-seasonexcept during the one in school day athletic period in baseball, basketball, football, soccer, softball, or volleyball. 'Schools and school booster clubs may not providefunds, fees, or transportation for non- school activities.

GENERAL ELIGIBILITY RULESAccording to UIL standards, students could be eligible to represent their school in interscholastic activities if they:'are not 19 years of age or older on or before Septmeber 1 of the current scholastic year. (See 446 of the Constitution and Contest Rules for exception.)• have not graduated from high school. • are full-time day students in a participant high school they wish to represent. • are meeting academic standards required bystate law .• are enrolled by the sixth class day of the current school year or have been in attendance for fifteen calendar days immediately preceding a varsity contest. •initially enrolled in the ninth grade not more than four years ago • have not been recruited. (Does not apply to college recruiting as permitted by rule.) • live withparents inside the school attendance zone their first year of attendance. (Parent residence applies to varsity athletic eligibility only.) When the parents do not resideinside the district attendance zone the student could be eligible if: the student has been in continuous attendance for at least one calendar year and has not enrolled atanother school; no inducement is given to the student to attend school (for example: students or their parents must pay their room and board when they do not live withare relative; students driving back into the district should pay their own transportation costs); and it is not a violation oflocal school or TEA policies for the student tocontinue attending the school. Students placed by the Texas Youth Commission are covered under Custodial Residence (see Section 442 of the Constitution and contestRules.) • did not change schools for athletic purposes' have not represented a college in a contest· have observed all provisions of the Awards Rule' have not violatedany provision of the summer camp rules. Incoming 10-12 grade students shall not attend a baseball, basketball, football, soccer, or volleyball camp in which sevenththrough twelfth grade coach from their school district attendance zone, works with, instructs, transports or registers that student in the camp. Students who will be ingrades 7, 8, and 9 may attend one baseball, one basketball, one football one soccer, one softball, and one volleyball camp in which a coach from their school districtattendance zone is employed, for no more than six consecutive days each summer in each type of sports camp. Baseball, Basketball, Football, Soccer, Softball, andVolleyball camps where school personnel work with their own students may be held in May, after the last day of school, June, July, and August prior to the secondMonday in August. If such camps are sponsored by school district personnel, they must be held within the boundaries of the school district and the superintendent or hisdesignee shall approve the schedule fees .• have observed all provisions of the Athletic Amateur Rule. Students may not accept money or other valuable consideration(tangible or intangible property or service including anything that is usable, wearable, salable, or consumable) for participating in any athletic sport during any part ofthe year. Athletes shall not receive valuable consideration for allowing their names to be used for the promotion of any product, plan or service. Students whoinadvertently violate the amateur rule by accepting valuable consideration may regain athletic eligibility by returning the valuable consideration. If the individualsreturn the valuable consideration within 30 days after they are informed of the rule violation, they regain their athletic eligibility when they return it. If they fail toreturn it within 30 days, they remain ineligible for one year from when they accepted it. During the period of time from when students receive valuable considerationuntil they return it, they are ineligible for all varsity athletic competition in the sport in which the violation occurred. Minimum penalty for participating in a contestwhile ineligible is forfeiture of the contest.

ACKNOWLEDGEMENT OF RULESAttention 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 participatein 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 formsigned by a parent must also be on file at your school.

HELMET WARNINGNo helmet can prevent all head or neck injuries a player might receive while participating in athletics. Do not use the helmet to butt, ram or spear an opposing player.This is in violation of the rules and such use can result in severe head and neck injuries, paralysis or death to you and possible injury to your opponent. We furtheracknowledge that, pursuant to the Texas Tort Claims Act, the Alvin Independent School District cannot be held liable for any injuries sustained in training orInterscholastic Competition, and we therefore agree that no legal action may be brought against Alvin Independent School District arising from any such injuries.

PARENT OR GUARDIAN'S PERMITIINFORMED CONSENTI 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 theschool 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. Neitherthe University Interscholastic League nor the high school assumes any responsibility in case an accident occurs. I have read and understand the UniversityInterscholastic League rules listed above and agree that my son/daughter will abide by all of the University Interscholastic League rules. The undersigned agrees to beresponsible for the safe return of all equipment issued by the school to the above named student. If, in the judgement of any representatives of the school, the abovestudent 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 givento said student by any physician, athletic trainer, nurse, hospital, or school representative; and I do hereby agree to indemnify and save harmless the school and anyrepresentative from any claim by any person whomsoever on account of such care and treatment of said student.

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

o Baseballo Golfo Soccer

o Footballo Swimming & Divingo Team Tennis

o Softballo Track & Fieldo Volleyball

o Tenniso Power Liftingo Gymnastics

o Basketballo Cross Countryo Water Polo

I have read and understood the (1) Medical History, (2) Physical Examination, (3) U.LL. Acknowledgement of Rules, (4) Parent or Guardian's Permit, (5) GeneralInformation and University Interscholastic League rules, (6) Athletic Information Release, (7) Drug Testing Consent, (8) Athletic Policies, (9) Illegal Steroid Use, and Ipermit my child to participate under these conditions. I have completed the information to the best of my knowledge and it is true and correct. The UIL ParentInformation Manual regarding health and safety issues is located at on the web at: http://www.uiltexas.orglfiles/athletics/manuals/parent-information-manual.pdf or canbe obtained in the athletic office at Alvin H.S. and Manvel H. S. I understand that failure to provide accurate and truthful information on UIL forms could subject thestudent in question to penalties determined by the UIL.

Your signature below gives authorization that is necessary for the school district, its athletic trainers, coaches, associated physicians and student insurance personnel toshare information concerning medical diagnosis and treatment for your student.I have been provided the UIL Parent Information Manual regarding health aud safety issues including concussions and my responsibilities as aparent/guardian. I understand that failure to provide accurate and trutbful information on UIL forms could subject the student in question to penaltiesdetermined by the VlL. I have read the regulations cited above and agree to follow the rules.

Signature of Parent/ Guardian _ Date _

Signature ofStudent _ Date _

PREPARTICIPATION PHYSICAL EVALUATION -- MEDICAL HISTORY REVISED 1·6-09

This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) and student in order for the student to participate in athletic activities. Thesequestions are designed to determine if the student has developed any condition which would make it hazardous to participate in an athletic event.Student's Name: (print) Sex Age Date of Birth _Address Phone. _~ade School _

Personal Physician Phone _

In case of emergency, contact:

Name Relationship Phone (H) (W)

Explain "Yes" answers in the box below**. Circle questions you don't know the answers to. Any Yes answer to questions 1,2,3,4,S,or 6 requires furthermedical evaluation which may include a physical examination. Written clearance from a physician, physician assistant, chiropractor, or nurse practitioner isre uired before any participation ill UIL practices, games or matches

Yes NoD D

0 00 00 00 00 qJ0 00 00 00 0

0 0

0 00 {]

0 00 0

S.6.7.

13.Yesoooo

Nooooo14.

Have you ever gotten unexpectedly short of breath withexercise?Do you have asthma?Do you have seasonal allergies that require medical treatment?Do you use any special protective or corrective equipment ordevices that aren't usually used for your sport or position (forexample, knee brace, special neck roll, foot orthotics, retaineron your teeth, hearing aid)?Have you ever had a sprain, strain, or swelling after injury?Have you broken or fractured any bones or dislocated anyjoints?Have you had any other problems with pain or swelling inmuscles, tendons, bones, or joints?If yes, check appropriate box and explain below.

ooo

ooo

IS.

0 Head 0 Elbow 0 Hip0 Neck 0 Forearm 0 Thigh0 Back 0 Wrist 0 Knee0 Chest 0 Hand 0 Shin/Calf0 Shoulder 0 Finger 0 Ankle0 Upper Arm 0 Foot

oooo

If, between this date and the beginning of athletic competition, any illness or injury should occur that may limit this student's participation, I agree to notify the schoolauthorities of such illness or injury.I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Failure to provide truthful responses couldsubject the student in question to penalties determined by the llLStudent Signature: Parent/Guardian Signature: Date:

Tms FORM MUST BE ON FILE PRIOR TO PARTICIPATION IN ANY PRACTICE, SCRIMMAGE OR CONTEST BEFORE, DURING OR AFTER SCHOOL.For School Use Only:This Medical History Form was reviewed by: Printed Name Date Signature' _

PREPARTICIPATION PHYSICAL EVALUATION -- PHYSICAL EXAMINATION

Height Weight. _

Student's Name _~~~~_~~~ =~Sex Age __ ~ Date of Birth,_~_~~~ _

% Body fat (optional) Pulse _ BP_/_(_/_,_/_)brachial blood pressure while sitting

Vision R 20/___ L 20/_ Corrected: 0 YON Pupils: 0 Equal 0 Unequal

As a minimum requirement, this Physical Examination Form must be completed prior to junior high athletic participation andagain prior to first and third years of high school athletic participation. It must be completed if there are yes answers to specificquestions on the student's MEDICALHISTORY FORM on the reverse side. * Local district policy may require an annual physicalexam.

MEDICALAppearanceEyeslEars/N ose/ThroatLymph NodesHeart-Auscultation of the heart inthe supine position.Heart-Auscultation of the heart inthe standing position.Heart-Lower extremity pulsesPulsesLungsAbdomenGenitalia (males only)SkinMarfan's stigmata (arachnodactyly,pectus excavatum, jointhypermobility, scoliosis)

NORMAL ABNORMAL FINDINGS INITIALS*

MUSCULOSKELETALNeckBackShoulder/ArmElbowlForearmWrist/HandHiprrhighKneeLeg/AnkleFoot

*statlOn-based exammanon only

CLEARANCEo Clearedo Cleared after completing evaluation/rehabilitation for: _

o Not cleared for: Reason: _Recommendations: _

The following information must be filled in and signed by either a Physician, a Physician Assistant licensed by a State Board ofPhysician Assistant Examiners, a Registered Nurse recognized as an Advanced Practice Nurse by the Board of Nurse Examiners,or a Doctor of Chiropractic. Examination forms signed by any other health care practitioner, will not be accepted.Name (print/type) Date of Examination: _Address: _

Phone Number: _

Signature:Must be completed before a student participates in any practice, before, during or after school, (both in-season and out-of-season) or games/matches.

University Interscholastic League

Parent and Student Agreement/Acknowledgement FormAnabolic Steroid Use and Random Steroid Testing

• Texas state law prohibits possessing, dispensing, delivering or administering a steroid in amanner not allowed by state law.

• Texas state law also provides that body building, muscle enhancement or the increase in musclebulk or strength through the use of a steroid by a person who is in good health is not a validmedical purpose.

• Texas state law requires that only a licensed practitioner with prescriptive authority may prescribea steroid for a person.

• Any violation of state law concerning steroids is a criminal offense punishable by confinement injailor 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 asdefined in the UIL Anabolic Steroid Testing Program Protocol. I have read this form and understand that Imay be asked to submit to testing for the presence of anabolic steroids in my body, and I do herebyagree to submit to such testing and analysis by a certified laboratory. I further understand and agree thatthe results of the steroid testing may be provided to certain individuals in my high school as specified inthe UIL Anabolic Steroid Testing Program Protocol which is available on the UIL website atwww.uiltexas.org. I understand and agree that the results of steroid testing will be held confidential tothe extent required by law. I understand that failure to provide accurate and truthful information couldsubject 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 Ihave read this form and understand that my student must refrain from anabolic steroid use and may beasked to submit to testing for the presence of anabolic steroids in his/her body. I do hereby agree tosubmit my child to such testing and analysis by a certified laboratory. I further understand and agree thatthe results of the steroid testing may be provided to certain individuals in my student's high school asspecified in the UIL Anabolic Steroid Testing Program Protocol which is available on the UIL website atwww.uiltexas.org. I understand and agree that the results of steroid testing will be held confidential tothe extent required by law. I understand that failure to provide accurate and truthful information couldsubject my student to penalties as determined by UIL.

Name (Print): _

Signature: Date: _

Relationship to student: _

Steroid Agreement 2011-2012

Alvin Independent School DistrictSTUDENT AND PARENT/GUARDIAN CONSENT TO RANDOM DRUG TESTING

Manvel High School 2011 - 2012

Last Name First Name Middle Initial Grade Level

Social Security Number Manvel H.S. Student I.D. Number Home Phone( )

MHS Activities Student Involved In (Example: Band, One-Act Play, FFA, Baseball, etc) MHS Driving PermitYes No

Name of Parenti Guardian Business/Cell Phone

( )

Statement of Purpose and IntentParticipation in after school extracurricular activities and/or parking on campus in the Alvin IndependentSchool District (herein after referred to as the 'District') is a privilege. These students carry aresponsibility to themselves, their fellow students, their parents, and their school to set the highest possibleexamples of conduct, which includes avoiding the use of illegal drugs, performance-enhancing drugs,and/or alcohol.ParticipationEach student who desires to participate in competitive after school extracurricular activities and/or parkingpermit privileges shall be provided with written information regarding the District's random drug testingpolicy and a 'Student and Parent/Guardian Consent to Random Drug Testing' form which shall be read,signed, and dated by the student, parent and/or person otherwise in lawful control of the student. Theconsent requires the student to provide a urine sample to be tested for illegal drugs, performance-enhancingdrugs, and/or alcohol when chosen through the random selection process. No student shall be allowed topractice or participate in any competitive after school extracurricular activities and/or parking permitprivileges until the 'Student and Parent/Guardian Consent to Random Drug Testing' form is properlysigned and returned.Student AuthorizationI, the above-named student, understand after having read the information regarding the District's randomdrug testing that, out of care for my health and safety and that of other students, the District will enforce therules applying to the use of illegal drugs, performance-enhancing drugs, and/or alcohol. As a member ofone of the groups designated for inclusion in random drug testing, I realize that the personal decision that Imake daily in regard to the consumption/use of illegal drugs, performance-enhancing drugs, and/or alcoholmay affect my health and well being as the possible endangerment ofthose around me and reflect upon thegroup with which I am associated. IfI choose to violate the random drug testing policy regarding the useof illegal drugs, performance-enhancing drugs, and/or alcohol any time while I am involved in any activity,including in-season or off-season activities, and/or parking permit privileges, I understand upondetermination of the violation, I will be subject to restrictions as outlined in the random drug testing policy.

I Signatnre of Student Participant I_D_a_t_e _

Parent/Guardian AuthorizationWe have read and understand the District's random drug testing policy. As the parent and/or personmaintaining lawful control of the above-named student, we desire that he/she participate in the competitiveafter school extracurricular activities and/or parking permit privileges of the District, and we herebyvoluntarily agree to be subject to the terms of the random drug testing policy. We accept the method ofobtaining urine samples, testing and analysis of such specimens, and all other aspects of the program. Wefurther agree and consent to the disclosure of the sampling, testing, results, and restrictions as provided inthe rogram.Signature of Parent/Guardian Date