Shadow Ridge Middle School Athletics Online Form Checklist

Shadow Ridge Middle School
Athletics
Online Form Checklist
The following form s m ust be filled online before the end of school.
The form s can be found at https://lewisvilleisd.rankonesport.com .
UIL Concussion
UIL Steroid
Extracurricular Code of Conduct
Cardiac Awareness
Em ergency Travel Card
M edical Info Release
UIL Acknowledgem ent of Rules
SRMS Form Checklist
All form s m ust be turned in to SRM S coaches before the end of school. The only
exception is the sports physical which is due by orientation in August. Please
understand that your student will not be able to tryout without a physical.
Field Trip
Athlete Transportation Form
Physical (returned before orientation in August)
The signatures below show that we have read all of the expectations and policies of SRMS athletics. We agree
to support the coaches in their efforts to train and achieve the highest level of physical fitness which will
include running, flexibility, strength and endurance.
Parent Signature: __________________________________________________________________
Student Signature: _________________________________________________________________
Shadow Ridge Panthers Athletics
We are excited to have your student in the Athletics Department at Shadow Ridge. Included are the
expectations and requirements for participation in athletics at SRMS.
• Uniform
Orders may be placed online at http://www.lewislet.com or you can go directly
to Lewisville Lettering to fill out a form and order your child’s uniform. (701B S. Old
Orchard Lewisville, 75067)
Gray Shadow Ridge T-shirt
Navy shorts
If students do not have the SRMS uniform, they are to wear a plain gray t-shirt OR any Shadow Ridge
Middle School T-Shirt (no sleeveless shirts) and plain navy or black shorts (no denim).
Sweat shirts and sweat pants may be purchased at Lewisville Lettering. Sweats are needed for cold
weather. Students will be expected to dress out and participate each day
full credit.
for
• Expectations
1. All student athletes are to maintain a 70% average in all classes each nine weeks. If a
student fails more than one nine weeks, they may be dismissed from the athletic period.
2. All athletes are expected to participate in one sport.
3. If a student makes one of the athletic teams, they are to attend all games,
tournaments, matches, or meets.
4. If a student is ill or injured and is unable to participate, they must bring a signed note
from a parent/guardian stating the reason for non-participation. Students who do not
participate will be given an alternative assignment or make-up workout.
*Maximum non-participation days are 3 days per nine weeks with parent
note. After this, students will lose participation points.
5. A physician’s note will be expected if the student is to be out more than 2 days
consecutively. Please have the doctor clearly state the student’s restriction and length
of time they are to be restricted.
*Students that have participation restrictions for long periods will be asked
to do alternative writing or research.
6. Students and parents are expected to have a positive attitude and be respectful to
teammates, coaches, officials, and opponents. Students will be expected to follow the
coaches’ instructions and not be a distraction to others during workouts or athletic
events.
*Parents: If you need to speak with a coach after an athletic event, please
schedule a parent conference.
7. Students will be given a locker with a combination lock. Students are responsible for
making sure that their lockers are closed and locked when leaving the locker room.
Students will be held responsible for any items that are lost if their locker is not locked.
*To reduce the loss of valuables: Students should never share lockers or share
their combinations with anyone.*
• Grading
Students are graded in the following areas:
Dress: 100 points per week
Participation: 100 points per week
Athletes are to follow the expectations listed above. They are to
cooperate, be respectful, responsible, and show self-control. When an
infraction occurs, 5 points will be deducted from the student’s participation
grade.
M ajor Grades:
Mile Run
Fitness Testing
Strength and Endurance Testing
• Additional 7 th Grade Requirements
1. All 7th grade athletes must try out for every sport except soccer.
2. Practice times will be 7th period as well as after school when in season.
3. Entrance into 8th grade athletics will be granted if an athlete follows all
expectations listed above.
• Additional 8 th Grade Requirements
1. Practice times will be before school and will continue through first period when in
season.
**Students that choose not to meet the expectations of the athletic program will
have consequences associated with their behavior.
This may include dismissal from athletics. **
LISD ATHLETE TRANSPORTATION RELEASE FORM
Date: 2014-2015 school year______School: Shadow Ridge Middle School
To Whom It May Concern:
My daughter / son __________________________________ will be riding home
from Game and Site (TBA) (event & site) with me. I, as the parent, have notified
the coach personally and understand the school will be released from liability as
soon as the facility is left. I also understand the school district prefers all athletes to
ride to and from all away events on school provided transportation and that this is
an exceptional situation.
_____________________________
Printed name of Parent / Guardian
_________________________
Signature of Parent / Guardian
Lewisville Independent School District
School Related Absences
Parent/Guardian Form
I am aware that __________________________________, ID#______________ will be leaving
(Name of Student)
2014-­‐2015 to participate in a school approved/related
__________________________
on ______________
Shadow Ridge (Name of School)
(Date)
activity. The activity involves:
_____Athletics
X _____Band/Choral
_____Speech/Debate _____UIL Events/Competition (other than athletics/band)
_____Field Trips
_____Vocational Contest
_____Other_________________________________
(Please List)
The Location /Destination of this Trip/Activity is____________________________________.
Time of School Related Absence:
All day ________
Morning _______
Afternoon ______
X Other _________
_________________________________________
(Signature of Parent/Guardian, Emancipated Minor, 18 Year Old)
_________________
(Date)
__________________________
(Telephone Number of Parent/Guardian)
If this permission form is not received by the school by the day of an event, the student will not
be allowed to leave school to attend.
It is a Texas Education Association rule and a Lewisville Independent School
District policy that this form be completed for all situations where a child leaves
a school during the school day to attend a school-related activity.
My Documents/Attendance Notebook/School Related Activity
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. These
questions 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__________________________________
Grade_______________________________________ 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, 5, or 6 requires further
medical evaluation which may include a physical examination. Written clearance from a physician, physician assistant, chiropractor, or nurse practitioner is
required before any participation in UIL practices, games or matches
Yes
1.
Have you had a medical illness or injury since your last check
up or sports physical?
Have you been hospitalized overnight in the past year?
Have you ever had surgery?
Have you ever passed out during or after exercise?
Have you ever had chest pain during or after exercise?
Do you get tired more quickly than your friends do during
exercise?
Have you ever had racing of your heart or skipped heartbeats?
Have you had high blood pressure or high cholesterol?
Have you ever been told you have a heart murmur?
Has any family member or relative died of heart problems or of
sudden unexpected death before age 50?
Has any family member been diagnosed with enlarged heart,
(dilated cardiomyopathy), hypertrophic cardiomyopathy, long
QT syndrome or other ion channelpathy (Brugada syndrome,
etc), Marfan's syndrome, or abnormal heart rhythm?
Have you had a severe viral infection (for example,
myocarditis or mononucleosis) within the last month?
Has a physician ever denied or restricted your participation in
sports for any heart problems?
Have you ever had a head injury or concussion?
Have you ever been knocked out, become unconscious, or lost
your memory?
If yes, how many
When was the last
times?
concussion?
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
How severe was each one? (Explain below)
Have you ever had a seizure?
Do you have frequent or severe headaches?
Have you ever had numbness or tingling in your arms, hands,
legs, or feet?
Have you ever had a stinger, burner, or pinched nerve?
Are you missing any paired organs?
Are you under a doctor’s care?
Are you currently taking any prescription or non-prescription
(over-the-counter) medication or pills or using an inhaler?
Do you have any allergies (for example, to pollen, medicine,
food, or stinging insects)?
Have you ever been dizzy during or after exercise?
Do you have any current skin problems (for example, itching,
rashes, acne, warts, fungus, or blisters)?
Have you ever become ill from exercising in the heat?
Have you had any problems with your eyes or vision?
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No
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13.
14.
15.
Have you ever gotten unexpectedly short of breath with
exercise?
Do you have asthma?
Do you have seasonal allergies that require medical treatment?
Do you use any special protective or corrective equipment or
devices that aren't usually used for your sport or position (for
example, knee brace, special neck roll, foot orthotics, retainer
on your teeth, hearing aid)?
Have you ever had a sprain, strain, or swelling after injury?
Have you broken or fractured any bones or dislocated any
joints?
Have you had any other problems with pain or swelling in
muscles, tendons, bones, or joints?
If yes, check appropriate box and explain below.
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16.
Head
Neck
Back
Chest
Shoulder
Upper Arm
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Elbow
Forearm
Wrist
Hand
Finger
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Yes
No
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Hip
Thigh
Knee
Shin/Calf
Ankle
Foot
Do you want to weigh more or less than you do now?
Do you lose weight regularly to meet weight requirements for
your sport?
17. Do you feel stressed out?
18. Have you ever been diagnosed with or treated for sickle cell trait
or sickle cell disease?
Females Only
19. When was your first menstrual period?
When was your most recent menstrual period?
How much time do you usually have from the start of one
period to the start of another?
How many periods have you had in the last year?
What was the longest time between periods in the last year?
An individual answering in the affirmative to any question relating to a possible
cardiovascular health issue (question three above), as identified on the form, should be
restricted from further participation until the individual is examined and cleared by a
physician, physician assistant, chiropractor, or nurse practitioner.
**EXPLAIN ‘YES’ ANSWERS IN THE BOX BELOW (attach another sheet if necessary):
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 school assumes any responsibility in case an accident occurs.
If, in the judgment of any representative of the school, the above student should need 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 said student by any physician, athletic trainer, nurse or school representative. I do hereby
agree to indemnify and save harmless the school and any school or hospital representative from any claim by any person on account of such care and treatment of said
student.
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 school
authorities 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 could
subject the student in question to penalties determined by the UIL
Student Signature: _________________________________________Parent/Guardian Signature:____________________________________ Date: ________________
THIS 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
Student's Name _________________________________ Sex _______ Age _______ Date of Birth _________________________
Height ______
Weight________
% Body fat (optional) ________
Pulse __________
BP____/____ (____/____, ____/____)
brachial blood pressure while sitting
Vision R 20/______ L 20/___
Corrected:
Y
N
Pupils:
Equal
Unequal
As a minimum requirement, this Physical Examination Form must be completed prior to junior high athletic participation and
again prior to first and third years of high school athletic participation. It must be completed if there are yes answers to specific
questions on the student's MEDICAL HISTORY FORM on the reverse side. * Local district policy may require an annual physical
exam.
NORMAL
ABNORMAL FINDINGS
INITIALS*
MEDICAL
Appearance
Eyes/Ears/Nose/Throat
Lymph Nodes
Heart-Auscultation of the heart in
the supine position.
Heart-Auscultation of the heart in
the standing position.
Heart-Lower extremity pulses
Pulses
Lungs
Abdomen
Genitalia (males only)
Skin
Marfan’s stigmata (arachnodactyly,
pectus excavatum, joint
hypermobility, scoliosis)
MUSCULOSKELETAL
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand
Hip/Thigh
Knee
Leg/Ankle
Foot
*station-based examination only
CLEARANCE
 Cleared
 Cleared after completing evaluation/rehabilitation for: __________________________________________________________
_________________________________________________________________________________________________________
 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 of
Physician 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.
Shadow Ridge Uniforms
*Performance Wear Available
Students are allowed to wear a plain gray shirt and plain navy shorts.
We will also allow students to wear any SRMS shirt.
To order Uniforms On Line Please go to
https://www.agpestores.com/lewislet/groups.php and select:
Orders can be placed in person at:
Lewisville Lettering
701-B S. Old Orchard Ln.
Lewisville, TX 75067
HOURS: Monday - Friday 9:00 - 6:00
PHONE:(972) 221-7286
We recogmind placing all orders before July 31st.