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Wimberley independent school district uil participation form

WIMBERLEY INDEPENDENT SCHOOL DISTRICT UIL PARTICIPATION FORM THIS DOCUMENT MUST BE COMPLETED EACH YEAR BEFORE PARTICIPATION
Name: ________________________________________ Date of Birth: ________________________
Home Address: _____________________________________ City, Zip: _______________________
Home Phone: __________________________ E-mail address: _______________________________
Grade (2013-2014): ______________________ Sports: ____________________________________
Mother’s Name: ______________________________ Work #: _______________________________
Father’s Name: _______________________________ Work #: _______________________________
Mom’s Cell: _______________________________ Dad’s Cell: _______________________________
Additional contact numbers (if parent or guardian cannot be reached):
Name: __________________________ Home #: _______________ Work/Cell #: ________________
ASSUMPTION OF RISK/RELEASE OF ALL CLAIMS: All athletes will be coached, instructed and conditioned
to compete at the peak of their abilities. Along with competition and effort to acquire excellence is the possibility of
injury. Despite efforts made by WISD coaches and personnel to provide proper conditioning, protective equipment
and safety practices, not all injuries are preventable and severe injuries can occur during athletic participation. I
hereby release and discharge the WISD employees and officers from all claims, demands, actions, judgments, and
executions which I may have or executors or administrators may have or claim to have against the WISD employees,
officers or parent-volunteers for all personal injuries, known or unknown, and to all known or unknown injuries to
property, real or personal, caused by or arising out of participation in athletics including travel and related activities.

MEDICATIONS
: The WISD Athletic Trainer is hereby given my consent to administer the non-prescription items
listed below.
Y N Y N Y N
Acetaminophen: Ibuprofen: Antacids:
(i.e. Tylenol) _______ _______ (i.e. Advil) ______ ______ (i.e. Tums) ______ ______
Anti-diarrheal: Naproxen:
(i.e. Immodium) ________ _______ (i.e. Aleve) ______ ______ Gatorade: ______ ______
Antibiotic Topical adrenocorticoids:
Ointment: _______ _______ (Insect sting relief) ______ ______
***Any medication the athlete may require on a regular basis must be indicated on the physical.*** *** It is recommended that in the case of asthma, an extra inhaler be given to the athletic trainer.***
DOCTOR REFERRAL PROCEDURE: I understand that if the above named student requires medical attention
as a result of an athletic injury, a doctor referral or hospital/emergency room visit will be initiated by the Athletic
Trainer. If, in the judgment of any representative of WISD the above named student requires immediate care and
treatment as a result of an injury or sickness, I do hereby request, authorize and consent to such care and treatment as
may be given to said student by any physician, trainer, nurse, hospital or school representative; and I do hereby agree
to save harmless the district and any district representative from any claim by any person on account of such care
and treatment of said student.
INJURY NOTIFICATION PROCEDURE: It is the athlete’s and parent’s responsibility to make the Athletic
Trainer aware of any injury occurring in the athletic programs. Notification should be made AT THE TIME OF
INJURY or within 48 hours, so proper medical attention is given. The Athletic Trainer is to be notified of any
changes of condition that differs from the physical and medical screening, and is indicated by the means of
WRITTEN ORDERS BY THE DOCTOR or medical facility. This notification includes limited practices, required
treatments, etc.
I hereby certify that I fully understand the ASSUMPTION OF RISK, permit the above mentioned non-prescription
drugs to be administered as needed, the DOCTOR REFERRAL PROCEDURE, and INJURY NOTIFICATION
PROCEDURE statement for my son/daughter’s participation in athletics for the Wimberley Independent School
District (WISD).
Signature of Parent/Guardian: _________________________________________ Date: _______________

Source: http://www.wimberleyisd.net/PDF/student_parent_forms/Athletics/WHS%20Emergency%20Participation%20Form%202013-2014.pdf

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