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Mayes.sjh.wallerisd.schoolfusion.us

Waller Independent School District 2012-2013
STUDENT’S NAME (Please Print):_________________________________________________________________
CIRCLE SCHOOL THAT WILL BE ATTENDED IN 2012-2013: Waller JH Schultz JH Waller HS
DATE OF BIRTH: ________________ AGE________ Gender: ________ GRADE (2012-2013):9th 10th 11th 12th
HOME ADDRESS: ___________________________________________CITY/ZIP: _________________________
ALLERGIES: __________________________________ DRUG ALLERGIES: _____________________________

MALE PARENT OR GUARDIAN

FEMALE PARENT OR GUARDIAN

NAME_________________________________
NAME_________________________________

HOME #_______________________________

HOME #_______________________________

WORK #_______________________________

WORK #_______________________________

CELL #________________________________

CELL #________________________________
PLEASE LIST TWO ADDITIONAL EMERGENCY CONTACTS
NAME_________________________________

NAME_________________________________

RELATION_____________________________

RELATION_____________________________

PHONE________________________________

PHONE________________________________
(Applies to High School students athletes only)
Please sign here if you give consent for Waller ISD athletic trainers to administer non-prescription over the counter (OTC)
medicine to the above named student athlete. OTC medications includes, but not limited to Tylenol, Advil, Motrin IB, Aleve,
Pepto-Bismol, Imodium A-D, Benadryl, Sudafed, Emetrol, Robitussin, cough drops, electrolytes or generics.
IMPORTANT: If you are asthmatic and require an inhaler you must provide one to the Athletic Trainer before participating.

PARENT/GUARDIAN SIGNATURE: X_________________________________________
I hereby give my consent for the above student to compete in University Interscholastic League approved sports, and travel with the coach or representative of the school on any trips. 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 high school assumes any responsibility in case an accident occurs. I have read and understand the University Interscholastic League rules and agree that my son/daughter will abide by all of the University Interscholastic League rules. If, in the judgment of any representatives of the school, the above student needs 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 to said student by any physician, athletic trainer, nurse, hospital, or school representative; and I do hereby agree to indemnify and save harmless the school and any school representative from any claim by any person whomsoever on account of such care and treatment of said student. PARENT/GUARDIAN SIGNATURE X____________________________________ DATE: ____________
IMPORTANT!
ANY ATHLETE THAT SEES ANY PHYSICIAN FOR ANY REASON MUST HAVE A NOTE
FROM THAT PHYSICIAN TO RESUME PARTICIPATION.
GENERAL INFORMATION
School coaches may not:
Transport, register, or instruct student in grades 7-12 from their attendance zone in non-school baseball, basketball, football, soccer, softball, or volleyball camps (exception: school coaches may hold one 6-day camp in their school district for incoming 7th,8th and 9th grade students), Give any instruction or schedule any practice for an individual or a team during the off-season except during the one in school day athletic period in baseball, basketball, football, soccer, softball, or volleyball. Schools and school booster clubs may not provide funds, fees or transportation for non-school activities. GENERAL ELIGIBILTY RULES
According to UIL standards, students are eligible to represent their school in interscholastic activities
if they:

Are not 19 years of age or older on or before September 1 of the current scholastic year. (See 504 handicapped exception.) Are enrolled by the sixth class day of the current school year or have been in attendance for fifteen calendar days immediately preceding a varsity contest. Are full-time day students in a participant high school Initially enrolled in the ninth grade not more than four calendar years ago. Are meeting academic standards required by state law Live with their parents inside the school district attendance zone their first year of attendance. (Parent residence applies to varsity athletic eligibility only.) When the parents do not reside inside the district attendance zone the student could be eligible if: the student has been in continuous attendance for at least one calendar year and has not enrolled at another school; no inducement is given to the student to attend the school ( for example: students or their parents must pay their room and board when they do not live with a relative; students driving back into the district should pay their own transportation cost); and it is not a violation of local school or TEA policies for the student to continue attending the school. Students placed by the Texas Youth Commission are covered under Custodial Residence (see Section 442 of the Constitution and Contest Rules). Have observed all provisions of the Awards Rule. Have not represented a college in a contest. Have not been recruited. (Does not apply to college recruiting as permitted by rule.) Have not violated any provision of the summer camp rule. Incoming 10-12 grade students shall not attend a baseball, basketball, football, soccer, or volleyball camp in which a seventh through twelfth grade coach from their school district attendance zone, works with, instructs, transports or registers that student in the camp. Student who will be in grades 7, 8, and 9 may attend one baseball, one basketball, one football, one soccer, one softball and volleyball camp in which a coach from their school district attendance zone is employed, for no more than six consecutive days each summer in each type of sports camp. Baseball, Basketball, Football, Soccer, Softball, and Volleyball camps where school personnel work with their own students may be held in May, after the last day of school, June, July and August prior to second Monday in August. If such camps are sponsored by school district personnel, they must be held within the boundaries of the school district and the superintendent or his designee shall approve the schedule of fees. Have observed all provisions of the Athletic Amateur Rule. Students may not accept money or other valuable consideration (tangible or intangible property or service including anything that is usable, wearable, salable or consumable) for participating in any athletic sport during any part of the year. Athletes shall not allow their names to be used for the promotion of any product, plan or service. Students who inadvertently violate the amateur rule by accepting valuable consideration may regain athletic eligibility by returning the valuable consideration. If individuals return the valuable consideration within 30 days after they are informed of the rule violation, they regain their athletic eligibility when they return it. If they fail to return it within 30 days, they remain ineligible for one year from when they accepted it. During the period of time from when students received valuable consideration until they return it, they are ineligible for varsity athletic competition in the sport in which the violation occurred. Minimum penalty for participating in a contest while ineligible is forfeiture of the contest. Did not change schools for athletic purpose. HELMENT DISCLAIMER
WARNING: No helmet can prevent all head and neck injuries a player might receive while participating in their sport. Do not use a
helmet to butt, ram or spear an opposing player. This is a violation of the rules and may result in severe head or neck injuries,
paralysis or death to you and possible injury to your opponent.

I have read the regulations cited above and agree to follow the rules.

X_________________________________________ X________________________________________ ___________
STUDENT SGNATURE
PARENT/GUARDIAN SIGNATURE

_________________________________________ __ ______________________________________
PRINT NAME OF STUDENT

STUDENT’S ID NUMBER

Source: http://mayes.sjh.wallerisd.schoolfusion.us/modules/groups/homepagefiles/cms/1475181/File/schedules%202012%20and13/Athletic%20Physical%20Form%20Packet%2012.pdf

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