2018-19 MSDLT Student-Athlete Required Forms

Example: 317-555-1234

Example: 317-555-1234

I, as the Parent or Legal Guardian of the above named student have read the MSDLT Athletic Handbook.

1. In accordance with the rules of the IHSAA, I hereby give consent for the named student to participate in the athletic programs at MSDLT.
2. I acknowledge that the participant is assuming a certain risk of being injured and that even with the best coaching, use of protective equipment and strict observation of rules, injuries are still a possibility in organized athletics. On rare occasions these injuries can be so severe as to result in total disability, paralysis, or even death.
3. I consent to the disclosure by the school to the IHSAA of all required detailed financial (athletic or otherwise), scholastic and attendance records of the school, including records which may concern or be related to the student, unless the student is emancipated, in which case the student gives such consent.
4. I authorize responsible school personnel or their agents to oversee or provide emergency medical care to the student in the event of serious injury or in the event the parent/guardian cannot be reached in a timely manner.
5. I authorize the school to investigate and obtain information from police agencies, the probation department or any other source regarding events leading up to any arrest or filing of charges for an act which would be in violation of any of the athletic rules published as part of the student handbook.
6. I have been provided with a copy of the rules and regulations regarding athletic participation or received copies of those rules and regulations in the student handbook. I understand the rules and regulations and will comply with them as stated. I understand that the rules and regulations will be in effect for all athletes as long as they are a student at MSDLT and that the rules and regulations may be updated from time to time.
7. I understand that MSDLT has in place a "reasonable suspicion" drug testing policy and that school personnel may order a drug test on the student if reasonable suspicion exists.
8. I authorize MSDLT to post results/highlights containing my son's/daughter's name on the MSDLT websites.

By typing your the PARENT name below - this is acting as your electronic signature.

I have read the rules and regulations of the Indiana High School Athletic Association (IHSAA) and MSDLT and believe that I am eligible to represent my school in athletics. If accepted as a representative, I agree to abide by the rules and regulations of the IHSAA and my school. To the best of my knowledge, I have suffered no injury or illness in the past that would hinder my participation in my chosen sport(s).

By typing your STUDENT NAME below this is acting as your electronic signature

IC 20-34-7 and IC 20-34-8 require schools to distribute information sheets to inform and educate student athletes and their parents on the nature and risk of concussion, head injury and sudden cardiac arrest to student athletes, including the risks of continuing to play after concussion or head injury. These laws require that each year, before beginning practice for an interscholastic sport, a student athlete and the student athlete’s parents must be given an information sheet, and both must sign and return a form acknowledging receipt of the information to the student athlete’s coach.

IC 20-34-7 states that an interscholastic student athlete, in grades 5-12, who is suspected of sustaining a concussion or head injury in a practice or game, shall be removed from play at the time of injury and may not return to play until the student athlete has received a written clearance from a licensed health care provider trained in the evaluation and management of concussions and head injuries, and at least twenty-four hours have passed since the injury occurred.

IC 20-34-8 states that a student athlete who is suspected of experiencing symptoms of sudden cardiac arrest shall be removed from play and may not return to play until the coach has received verbal permission from a parent or legal guardian for the student athlete to return to play. Within twenty-four hours, this verbal permission must be replaced by a written statement from the parent or guardian.

Parent/Guardian - please read the attached fact sheets (links below) regarding concussion and sudden cardiac arrest and ensure that your student athlete has also received and read these fact sheets. After reading these fact sheets, please ensure that you and your student athlete sign this form, and have your student athlete return this form to his/her coach. Electronic Signatures below serve this purpose.

Concussion Fact Sheet: https://www.cdc.gov/headsup/pdfs/highschoolsports/athletes_fact_sheet-a.pdf

Concussion Fact Sheet (Spanish): https://www.cdc.gov/headsup/pdfs/highschoolsports/high_school_sports_athletes_fs_spanish_v2_508.pdf

Concussion Information Sheet: https://www.cdc.gov/headsup/pdfs/youthsports/parent_athlete_info_sheet-a.pdf

Concussion Information Sheet (Spanish):

Middle School Concussion Fact Sheet:

Middle School Concussion Fact Sheet (Spanish):

Concussion Fact Sheet for Parents:

Concussion Fact Sheet for Parents (Spanish):

Sudden Cardiac Arrest Fact Sheet for Parents:

Sudden Cardiac Arrest Fact Sheet for Parents (Spanish):

Sudden Cardiac Arrest Sheet for Student Athletes:

Sudden Cardiac Arrest Sheet for Student Athletes (Spanish):

I, as the Parent or Legal Guardian of the above named student(s) have read the Parent Information Fact Sheets on CONCUSSIONS and SUDDEN CARDIAC ARREST. I understand the nature and risk of concussion and head injury to student athletes, including the risks of continuing to play after concussion or head injury, and the symptoms of Sudden Cardiac Arrest.

By typing your the PARENT NAME below - this is acting as your electronic signature

By typing your STUDENT NAME below this is acting as your electronic signature

As parent or legal guardian for the Student listed above, I do hereby consent to the Student receiving athletic training services from Community Health Network. I understand that during the course of these services certain health information related to Student's athletic training services may be used and/or disclosed for treatment, payment or healthcare operations purposes, or as otherwise required by law. I further consent to certain health information being disclosed to school personnel, including but not limited to, coaches, school administration, and/or staff, as necessary. I understand this consent is subject to my revocation at any time, except to the extent that action has been taken in reliance on this consent. Otherwise, this consent shall expire at the end of the school year or the Student's current athletic season, whichever is later.

By typing your the PARENT NAME below - this is acting as your electronic signature

I hereby authorize Community and its personnel and/or agents, to disclose the protected health information (PHI) of my child as follows: The PHI of the Student that may be disclosed under this Authorization includes the records of physical examinations performed by Community to determine the Student's eligibility to participate in classroom or other school sponsored activities; records of evaluation; records and reports regarding the diagnosis and treatment of injuries which the Student incurred while engage in school sponsored activities, including but not limited to practice sessions, training and competition; and other records necessary to determine the Student's physical fitness to participate in school sponsored activities.
The Student's PHI may be disclosed to (1) the MSDLT principal, assistant principal, athletic director, coaches, teachers, school nurses or the members of the school's administrative staff or their designee, and (2) emergency personnel, hospitals, or any other health care professional or provider who evaluates, diagnosis or treats an injury, illness, or other condition incurred by the Student while participating in a school sponsored activity, as necessary to:
- Evaluate the Student's eligibility to participate in school sponsored activities, including but not limited to interscholastic or intramural sports programs, physical education classes or other classroom activities;
- Document the sports medicine services provided by Community and evaluate program outcomes;
- Resolve grievances; and
- Evaluate treatment alternatives.
I understand that Community has requested this Authorization to disclose PHI so that the school, together with Community, can make certain decisions about the Student's health and ability to participate in certain classroom and school sponsored activities in accordance with the Health Information Portability and Accountability Act (HIPPA). I also understand that the Student's participation in certain school sponsored activities is conditioned upon my signing this Authorization. I understand that I may revoke this Authorization in writing at any time prior to its expiration date, except to the extant that action has been taken by Community in reliance on this Authorization, by sending a written revocation, to the athletic trainer or his/her designee. I understand that the PHI released may be subject to re-disclosure by any recipient and no longer protected by federal and or state privacy laws. Expiration of Authorization: 1 year from date signed.

By typing your the PARENT NAME below - this is acting as your electronic signature

If student is 18 years old or will be in the following year, student must also sign.
By typing your STUDENT NAME below - this is acting as your electronic signature.

Example: 317-555-1234

Students cannot participate in any conditioning or practices until the physical is on file with the school. All four pages of physical must be submitted.
Here is a link to a blank phsyical form to take with you to your doctor's office: http://www.ihsaa.org/Portals/0/ihsaa/documents/quick%20resources/IHSAA%20PPE%202017-18.pdf

Once the physical is complete, you can upload below or submit to Athletic Office or Athletic Trainer.

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