The following information is very important to have on file in case of emergency situations. Please fill in the information to the best of your abilities. Please list any insurance coverage, including Champus, Medicare, Medicaid, accident policies, HMO's, etc. If you do not have insurance coverage, please check the "No Insurance" box.

The parent or guardian of the student recognizes that as a result of athletic participation, medical treatment on an emergency or non- emergency basis may be necessary and further recognize that school personnel may be unable to contact me for my consent for such medical care. I do hereby authorize in advance to such emergency and non-emergency care, including hospital care, as may be deemed necessary under the then existing circumstances. The purpose of this release is to authorize the school to obtain, through a physician of its choice, any medical care that may become reasonably necessary forthe student in the course of school athletic activities or school travel.

Additionally, I give my permission and consent for the evaluation and treatment of my child by the physicians at the CHRISTUS Health System, including CHRISTUS Saturday Sports Injury Clinic.

I hereby consent to and permit CHRISTUS Trinity Clinic Physicians/Staff (and/or their designee) to provide evaluation, medical treatment (including emergent or urgent treatment if necessary) to me/my child, including hospitalization and physician follow-up according to their medical judgment at the CHRISTUS Health System and/or its Saturday Morning Sports Injury Clinic.

I further authorize CHRISTUS Health System to obtain and release personal medical/insurance data about me for treatment payment or operations related to my injury, illness, physical examination(s) in accordance with the applicable state and federal privacy laws.

I am of sound mind and competent to sign this form.

I have read this form, understand it and agree to the terms and conditions.

I hereby authorize the physicians, athletic trainers, sports medicine staff and other health care personnel represent CHRISTUS Orthopedic & Sports Medicine Institute to release information regarding the student athlete's protected health information and related information regarding any injury or illness during the student athlete's training for and participation in athletics atSchool (the "School" This protected health information may concern the student athlete's medical status, medical condition, injuries, prognosis, diagnosis, athletic participation status, and related individually identifiable health information. This protected health information may be released to other health care providers, hospitals and/or medical clinics, Saturday Morning Clinics, and laboratories, athletic coaches, medical insurance coordinators, athletic and/or school administrators, chaplains and/or clergy members, and officials of Union Grove School District.

I understand that as a parent/legal guardian my authorization/consent to the disclosure of the student athlete's protected health information is a condition for the student athlete's participation in interscholastic sports at the School. I understand that the student athlete's protected health information is protected under federal law. I, the parent/legal guardian, understand that once information is disclosed per this authorization, the information is subject to re-disclosure by the recipient and may no longer be protected under federal law. I may revoke this authorizationat any time by notifying the School's athletic director in writing, but if I do, it will not have any effect on actions taken in reliance of my prior authorization. This authorization expires one year from the date it is signed.

NOTICE OF PRIVACY PRACTICES

By signing above I acknowledge that I have received or have been offered a copy of CHRISTUS Orthopedic & Sports Medicine Institute's Notice of Privacy Practices.

Definition of Concussion - means a complex pathophysiological process affecting the brain caused by a traumatic physical force or impact to the head or body, which may: (A) include temporary or prolonged altered brain function resulting in physical, cognitive, or emotional symptoms or altered sleep patterns; and (B) involve loss of consciousness.

Prevention - Teach and practice safe play & proper technique. - Follow the rules of play. - Make sure the required protective equipment is worn for all practices and games. - Protective equipment must fit properly and be inspected on a regular basis.

Signs and Symptoms of Concussion - The signs and symptoms of concussion may include but are not limited to: Headache, appears to be dazed or stunned, tinnitus (ringing in the ears), fatigue, slurred speech, nausea or vomiting, dizziness, loss of balance, blurry vi- sion, sensitive to light or noise, feel foggy or groggy, memory loss, or confusion.

Oversight - Each district shall appoint and approve a Concussion Oversight Team (COT The COT shall include at least one physician and an athletic trainer if one is employed by the school district. Other members may include: Advanced Practice Nurse, neuropsy- chologist or a physician's assistant. The COT is charged with developing the Return to Play protocol based on peer reviewed scientific evidence.

Treatment of Concussion - The student-athlete/cheerleader shall be removed from practice or participation immediately if suspected to have sustained a concussion. Every student-athlete/cheerleader suspected of sustaining a concussion shall be seen by a physician before they may return to athletic or cheerleading participation. The treatment for concussion is cognitive rest. Students should limit external stimulation such as watching television, playing video games, sending text messages, use of computer, and bright lights. When all signs and symptoms of concussion have cleared and the student has received written clearance from a physician, the student-athlete/cheerleader may begin their district's Return to Play protocol as determined by the Concussion Oversight Team.

Return to Play - According to the Texas Education Code, Section 38.157: A student removed from an interscholastic athletics practice or competition (including per UIL rule, cheerleading) under Section 38.156 may not be permitted to practice or participate again following the force or impact believed to have caused the concussion until: (1) the student has been evaluated, using established medical protocols based on peer-reviewed scientific evidence, by a treating physician chosen by the student or the student's parent or guardian or another person with legal authority to make medical decisions for the student; (2) the student has successfully completed each requirement of the return-to-play protocol established under Section 38.153 necessary for the student to return to play; (3) the treating physician has provided a written statement indicating that, in the physician's professional judgment, it is safe for the student to return to play; and (4) the student and the student's parent or guardian or another person with legal authority to make medical decisions for the student: (A) have acknowledged that the student has completed the requirements of the return-to-play protocol necessary for the student to return to play; (B) have provided the treating physician's written statement under Subdivision (3) to the person responsible for compliance with the return-to-play protocol under Subsection (c) and the person who has supervisory responsibilities under Subsection (c); and (C) have signed a consent form indicating that the person signing: (i) has been informed concerning and consents to the student participating in returning to play in accordance with the return-to- play protocol; (ii) understands the risks associated with the student returning to play and will comply with any ongoing requirements in the return-to-play protocol; (iii) consents to the disclosure to appropriate persons, consistent with the Health Insurance Portability and Accountability Act of 1996 (Pub. L. No. 104-191), of the treating physician's written statement under Subdivision (3) and, if any, the return-to-play recommenda- tions of the treating physician; and (iv) understands the immunity provisions under Section 38.159.

University Interscholastic League

Parent and Student Agreement/Acknowledgement Form Anabolic Steroid Use and Random Steroid Testing

• Texas state law prohibits possessing, dispensing, delivering or administering a steroid ina manner not allowed by state law.
• Texas state law also provides that body building, muscle enhancement or the increase in muscle bulk or strength through the use of a steroid by a person who is in good health is not a valid medical purpose.
• Texas state law requires that only a licensed practitioner with prescriptive authority may prescribe a steroid for a person.
• Any violation of state law concerning steroids is a criminal offense punishable by confinement in jail or 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 as defined in the UIL Anabolic Steroid Testing Program Protocol. I have read this form and understand that I may be asked to submit to testing for the presence of anabolic steroids in my body, and I do hereby agree to submit to such testing and analysis by a certified laboratory. I further understand and agree that the results of the steroid testing may be provided to certain individuals in my high school as specified in the UIL Anabolic Steroid Testing Program Protocol which is available on the UIL website at www.uiltexas.org. I understand and agree that the results of steroid testing will be held confidential to the extent required by law. I understand that failure to provide accurate and truthful information could subject me to penalties as determined by UIL.

PARENT/GUARDIAN CERTIFICATION AND ACKNOWLEDGEMENT

As a prerequisite to participation by my student in UIL athletic activities, I certify and acknowledge that I have read this form and understand that my student must refrain from anabolic steroid use and may be asked to submit to testing for the presence of anabolic steroids in his/her body. I do hereby agree to submit my child to such testing and analysis by a certified laboratory. I further understand and agree that the results of the steroid testing may be provided to certain individuals in my student's high school as specified in the UIL Anabolic Steroid Testing Program Protocol which is available on the UIL website at www.uiltexas.org. I understand and agree that the results of steroid testing will be held confidential to the extent required by law. I understand that failure to provide accurate and truthful information could subject my student to penalties as determined by UIL.