Fall Creek Valley Middle School: 2022-23 MSDLT Student-Athlete Required Form


Completion of this form and submission of the four-page student physical (ALL FOUR PAGES) is required prior to participating in any athletic conditioning or practices. If student-athlete is under the age of 18, form should be completed by the legal parent/guardian. Here is a link to a blank physical form to take with you to your doctor's office: https://www.ihsaa.org/Portals/0/ihsaa/documents/quick%20resources/2020-21%20Physical%20Form.pdf?ver=2020-01-17-154323-640 (If you would like to receive a copy of your responses, please select "Send me a copy of my responses" below.)

STUDENT INFORMATION

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Grade during the 2022-23 School Year*

NOTE: Phone # must be entered in this format, including hyphens 317-555-1234

ADDRESS

Note: Include Apt. #, if applicable.


PARENT/GUARDIAN INFORMATION

NOTE: Phone # must be entered in this format, including hyphens 317-555-1234

NOTE: Phone # must be entered in this format, including hyphens 317-555-1234

NOTE: Phone # must be entered in this format, including hyphens 317-555-1234

NOTE: Phone # must be entered in this format, including hyphens 317-555-1234

NOTE: Phone # must be entered in this format, including hyphens 317-555-1234

NOTE: Phone # must be entered in this format, including hyphens 317-555-1234


Athletic Eligibility

Read the Athletic Handbook here: http://www.ltschools.org/MediaLibraries/ltschools.org/Documents/Athletics/StudentAthleteHandbook.pdf


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

Concussion & Sudden Cardiac Arrest Information

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): https://www.cdc.gov/headsup/pdfs/youthsports/esp/parent_athlete_info_sheet_spanish-a.pdf Middle School Concussion Fact Sheet: https://www.cdc.gov/headsup/pdfs/highschoolsports/middleschool_athletes_fact_sheet-a.pdf Middle School Concussion Fact Sheet (Spanish): https://www.cdc.gov/headsup/pdfs/highschoolsports/middle_school_sports_athletes_fs_spanish_v2_508.pdf Concussion Fact Sheet for Parents: https://www.cdc.gov/headsup/pdfs/highschoolsports/parents_fact_sheet-a.pdf Concussion Fact Sheet for Parents (Spanish): https://www.cdc.gov/headsup/pdfs/highschoolsports/high_school_parents_fact_sheet_spanish_v3_508.pdf Sudden Cardiac Arrest Fact Sheet for Parents: https://www.doe.in.gov/sites/default/files/health/sudden-cardiac-arrest-fact-sheet-parents.pdf Sudden Cardiac Arrest Fact Sheet for Parents (Spanish): https://www.doe.in.gov/sites/default/files/health/sudden-cardiac-arrest-fact-sheet-parentsspanish.pdf Sudden Cardiac Arrest Sheet for Student Athletes: https://www.doe.in.gov/sites/default/files/health/sudden-cardiac-arrest-fact-sheet-student-athletes.pdf Sudden Cardiac Arrest Sheet for Student Athletes (Spanish): https://www.doe.in.gov/sites/default/files/health/sudden-cardiac-arrest-fact-sheet-student-athletesspanish.pdf


WAIVERS and AUTHORIZATIONS

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

Consent to Treat, HIPPA, FERPA - Community Health Network

NOTE: IF STUDENT ATHLETE IS 18 YEARS OR OLDER, HE/SHE MUST SIGN THIS AUTHORIZATION. IF THE STUDENT ATHLETE IS YOUNGER THAN 18, A PARENT OR GUARDIAN MUST SIGN THIS AUTHORIZATION. A STUDENT SHALL NOT BE CLEARED TO PARTICIPATE IN CERTAIN SCHOOL SPONSORED ACTIVITIES (INCLUDING BUT NOT LIMITED TO SPORTS PROGRAMS) IF THIS ACKNOWLEDGEMENT IS NOT SIGNED OR IF IT IS REVOKED.

By signing below, I acknowledge and hereby consent to Community providing first aid or medical treatment for my child in the event of an injury or an illness while participating in School’s athletic programs; and that Community will attempt to contact the student athlete’s parent/guardian. If a parent/guardian cannot be reached, Community will provide appropriate medical treatment believed to be in the best interest of the student athlete. I acknowledge and agree to provide the School with completed Emergency Contact Information (this form's aforementioned required information).

NOTE: IF STUDENT ATHLETE IS 18 YEARS OR OLDER, HE/SHE MUST SIGN THIS AUTHORIZATION. IF THE STUDENT ATHLETE IS YOUNGER THAN 18, A PARENT OR GUARDIAN MUST SIGN THIS AUTHORIZATION. A STUDENT SHALL NOT BE CLEARED TO PARTICIPATE IN CERTAIN SCHOOL SPONSORED ACTIVITIES (INCLUDING BUT NOT LIMITED TO SPORTS PROGRAMS) IF THIS ACKNOWLEDGEMENT IS NOT SIGNED OR IF IT IS REVOKED.

By signing below, I hereby authorize Community, including its employees and agents, to disclose minimally necessary protected health information (PHI) of my child listed on this form as follows: Community may disclose 1) records of physical examinations performed to determine student athlete's eligibility to participate in School sponsored activities; 2) records of therapeutic evaluations; 3) records and reports of diagnosis and treatment of injuries or illness experienced by the student athlete while engaged in School sponsored activities, including but not limited to athletic program practice sessions, training and competition; and 4) other records as necessary to determine Student Athlete's physical fitness to participate in school sponsored activities.


I hereby authorize minimally necessary PHI to be disclosed for the purposes described above to the following School personnel (“School Personnel”): 1) principal or assistant principal, athletic director, coaches, teachers, school nurses or other members of the School's administrative staff or their designees, and 2) emergency medical personnel, hospitals or any other health care professional or provider who


evaluates, diagnoses or treats an injury, illness or other condition incurred by the Student Athlete while participating in a school sponsored activity, as necessary to:


· Evaluate the Student Athlete’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 (HIPAA). 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 by sending written notice to the athletic trainer, except that such revocation will not affect action previously taken by Community in reliance on this Authorization. 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.

NOTE: IF STUDENT ATHLETE IS 18 YEARS OR OLDER, HE/SHE MUST SIGN THIS AUTHORIZATION. IF THE STUDENT ATHLETE IS YOUNGER THAN 18, A PARENT OR GUARDIAN MUST SIGN THIS AUTHORIZATION. A STUDENT SHALL NOT BE CLEARED TO PARTICIPATE IN CERTAIN SCHOOL SPONSORED ACTIVITIES (INCLUDING BUT NOT LIMITED TO SPORTS PROGRAMS) IF THIS ACKNOWLEDGEMENT IS NOT SIGNED OR IF IT IS REVOKED.


Community’s NOTICE OF PRIVACY PRACTICES (“NPP”) describes the policies and procedures that are designed to protect the privacy and security of student’s personal health information. The student athlete and/or parent/guardian have the right to receive a copy of the Notice of Privacy Practices prior to signing this Consent to Treat and Authorization to Release Information. The current Community NPP will be posted in the School's health clinic and in the athletic training room, and also on Community's website, with copies available upon request by asking the staff of the School health clinic or the athletic trainer.

NOTE: IF STUDENT ATHLETE IS 18 YEARS OR OLDER, HE/SHE MUST SIGN THIS AUTHORIZATION. IF THE STUDENT ATHLETE IS YOUNGER THAN 18, A PARENT OR GUARDIAN MUST SIGN THIS AUTHORIZATION. A STUDENT SHALL NOT BE CLEARED TO PARTICIPATE IN CERTAIN SCHOOL SPONSORED ACTIVITIES (INCLUDING BUT NOT LIMITED TO SPORTS PROGRAMS) IF THIS ACKNOWLEDGEMENT IS NOT SIGNED OR IF IT IS REVOKED.


Community’s NOTICE OF PRIVACY PRACTICES (“NPP”) describes the policies and procedures that are designed to protect the privacy and security of student’s personal health information. The student athlete and/or parent/guardian have the right to receive a copy of the Notice of Privacy Practices prior to signing this Consent to Treat and Authorization to Release Information. The current Community NPP will be posted in the School's health clinic and in the athletic training room, and also on Community's website, with copies available upon request by asking the staff of the School health clinic or the athletic trainer.


TRANSFER INFORMATION

Have you ever attended another high school?*

If you answered "yes" to the previous question, provide the name of the last high school that you attended.


PHYSICIAN INFORMATION

NOTE: Phone # must be entered in this format, including hyphens 317-555-1234

Emergency Medical Information

Please check all conditions that apply.

May a school representative administer the following? Check all that they may administer.

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PHYSICAL FORM

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 physical form to take with you to your doctor's office:


https://www.ihsaa.org/sites/default/files/documents/physical_form.pdf


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

Drag and drop files here or