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?  No                                                      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.       16. Head Neck Back Chest Shoulder Upper Arm      Elbow Forearm Wrist Hand Finger       Yes No                       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.