Saint Paul’s School – Sports Eligibility Packet – NEW ATHLETES

ATTENTION PARENTS:

Please find attached all of the paperwork that is required by the LHSAA for your child to be eligible to play sports in Louisiana. It is very important that all forms and all sections are filled out completely. If any form is missing signatures or dates, we will be required to return the forms to you delaying your child’s ability to participate in practice or games. The last four digits of the child’s Social Security number are required for registering your child with the LHSAA, and a birth certificate must be kept in each athlete’s athletic file as well as in his main school file.

If you have questions, please contact Claire Coutrado, Athletic Secretary, at clairec@stpauls.com or (985) 327-1848. Our goals are to keep files up-to-date, and to keep the boys involved.

NEW ATHLETES MUST SUBMIT THE FOLLOWING PAPERWORK BEFORE PARTICIPATING:

1. LHSAA Medical History EvaluationThe top of this form and the Parent’s Waiver is to be filled out and signed by parents and Section II, the bottomof the form, is to be filled out by the physician conducting the physical. Physicals are valid for one year from dateobtained.

2. LHSAA Substance Abuse/Misuse Contract and Consent FormThis form must be signed and dated by student, parent, principal and head coach.

3. LHSAA - Athletic Participation and Parental Permission FormPart I – Please fill out in entirety.Read eligibility requirements to make sure that none of these rules disqualifies your child.Part II – Parent’s Signature and Date

4. St. Paul’s School – Emergency InformationIt is important that we have updated information completed annually so that we can contact you if your child isinjured while under our care. It also gives us permission to have your child treated if immediate attention isneeded before you are available. Please include updated insurance information.

5. LHSAA Parent and Student-Athlete Concussion StatementDue to the passing of The Louisiana Youth Concussion Act in 2011, parents and athletes are required to sign aconcussion fact sheet annually as proof of your awareness of basic concussion protocol. This is a state law and isrequired for all sports.

6. Birth CertificateIf your child is playing sports at St. Paul’s for the first time, please supply a birth certificate with his athleticpacket. We are required to keep a copy in his athletic file.

7. LCMC Consent to Treatment and Waiver Liability FormBeginning with the 2018-19 school year our athletic trainers are provided by LCMC Sports Medicine Group. Thisform gives them permission for treatment.

8. LCMC OTC Permission formThis will allow our trainers to give over the counter medicine to your son if needed.Thank you for your help.

We look forward to another year of athletic success at St. Paul’s school.

LHSAA MEDICAL HISTORY EVALUATION IMPORTANT: This form must be completed annually, kept on file with the school, & is subject to inspection by the Rules Compliance Team.

Please Print

Name:___________________________________________________School:______________________________________________Grade:________Date:______________

Sport(s):_________________________________________________________Sex: M / F Date of Birth:_____________Age:______Cell Phone:_____________________

Home Address:___________________________________City:__________________________State:_____ Zip Code:___________Home Phone:____________________

Parent / Guardian:________________________________________________Employer:_______________________________________Work Phone:__________________

FAMILY MEDICAL HISTORY: Has any member of your family under age 50 had these conditions? Yes No Condition Whom Yes No Condition Whom Yes No Condition Whom

Heart Attack/Disease Sudden Death _____________ Arthritis _____________ Stroke High Blood Pressure _____________ Kidney Disease _____________ Diabetes Sickle Cell Trait/Anemia _____________ Epilepsy _____________

ATHLETE’S ORTHOPAEDIC HISTORY: Has the athlete had any of the following injuries? Yes No Condition Date Yes No Condition Date Yes No Condition Date

Head Injury / Concussion __________ Neck Injury / Stinger _________ Shoulder L / R __________ Elbow L / R __________ Arm / Wrist / Hand L / R _________ Back __________ Hip L / R __________ Thigh L / R _________ Knee L / R __________ Lower Leg L / R __________ Chronic Shin Splints _________ Ankle L / R __________ Foot L / R __________ Severe Muscle Strain _________ Pinched Nerve __________

Chest __________ Previous Surgeries:

ATHLETE MEDICAL HISTORY: Has the athlete had any of these conditions? Yes No Condition Yes No Condition Yes No Condition

Heart Murmur / Chest Pain / Tightness Asthma / Prescribed Inhaler Menstrual irregularities: Last Cycle: Seizures Shortness of breath / Coughing Rapid weight loss / gain Kidney Disease Hernia Take supplements/vitamins Irregular Heartbeat Knocked out / Concussion Heat related problems Single Testicle Heart Disease Recent Mononucleosi High Blood Pressure Diabetes Enlarged Spleen Dizzy / Fainting Liver Disease Sickle Cell Trait/Anemia Organ Loss (kidney, spleen, etc) Tuberculosis Overnight in hospital Surgery Prescribed EPI PEN Allergies (Food, Drugs)

Medications

List Dates for: Last Tetanus Shot: Measles Immunization: Meningitis Vaccine:

PARENTS’ WAIVER FORM To the best of our knowledge, we have given true & accurate information & hereby grant permission for the physical screening evaluation. We understand the

evaluation involves a limited examination and the screening is not intended to nor will it prevent injury or sudden death. We further understand that if the examination is provided without expectation of payment, there shall be no cause of action pursuant to Louisiana R.S. 9:2798 against the team volunteer health- care provider and/or employer under Louisiana law.

This waiver, executed on the date below by the undersigned medical doctor, osteopathic doctor, nurse practitioner or physician’s assistant and parent of the student athlete named above, is done so in compliance with Louisiana law with the full understanding that there shall be no cause of action for any loss or damage caused by any act or omission related to the health care services if rendered voluntarily and without expectation of payment herein unless such loss or damage was caused by gross negligence. Additionally, 1. If, in the judgment of a school representative, the named student-athlete needs care or treatment as a result of an injury

or sickness, I do hereby request, consent and authorize for such care as may be deemed necessary…………………………………………....Yes No 2. I understand that if the medical status of my child changes in any significant manner after his/her physical examination,

I will notify his/her principal of the change immediately…………………………………………………………………………………………………..Yes No

3. I give my permission for the athletic trainer to release information concerning my child’s injuries to the head coach/athleticdirector/principal of his/her school…………………………………………………………………………………………………………………………..Yes No

4. By my signature below, I am agreeing to allow my child’s medical history/exam form and all eligibility forms to be reviewedby the LHSAA or its Representative(s) ………………………………………………………………………………………………………………..……Yes No

Date Signed by Parent Signature of Parent Typed or Printed Name of Parent

II. COMPLETED ANNUALLY BY MEDICAL DOCTOR (MD), OSTEOPATHIC DR. (DO), NURSE PRACTITIONER (APRN) or PHYSICIAN’S ASSISTANT (PA)

GENERAL MEDICAL EXAM : OPTIONAL EXAMS: ORTHOPAEDIC EXAM : Norm Abnl VISION: Norm Abnl

ENT L:_______ R:_______ Corrected: _______ I. Spine / NeckLungs CervicalHeart DENTAL: ThoracicAbdomen 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 LumbarSkin 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 II. Upper Extremity Hernia Shoulder (if Needed) Elbow

COMMENTS: WristHand / Fingers

III. Lower Extremity Hip

Knee[ ] Student is cleared Ankle

[ ] Cleared after further evaluation and treatment for:

[ ] Not cleared for: __contact __non-contact

Printed Name of MD, DO, APRN or PA Signature of MD, DO, APRN or PA Date of Medical Examination

This physical expires 13 months from the date it was signed and dated by the MD, DO, APRN or PA.

Height ______________ Weight __________________ Blood Pressure________________ Pulse___________

From this limited screening I see no reason why this student cannot participate in athletics.

Revised 6/18

ST. PAUL'S SCHOOL - EMERGENCY/STUDENT INFORMATION FOR ATHLETES

STUDENT NAME:

(student)

DAD WORK #:

(other than parent)

EMERGENCY PHONE #:

*** I hereby consent for a qualified physician or surgeon to examine and prescribe or perform treatment, including surgery that is deemed advisable for the welfare of the above named student-athlete.

STUDENT CELL:

MOM WORK #:

BIRTHDATE:

ALLERGIES (IF ANY):

Parent/Guardian Name:

Parent/Guardian Signature:

Date:

PARENT/GUARDIAN:

STREET ADDRESS:

CITY/STATE/ZIP CODE:

HOME PHONE #:

MOM EMAIL ADDRESS:

EMERGENCY NAME:

DAD EMAIL ADDRESS:

STUDENT SS# (last 4 digits):

DAD CELL PHONE #:

MOM CELL PHONE #:

INSURANCE PHONE #:

INSURANCE MEMBER ID #:

INSURANCE GROUP #:

INSURANCE CO. NAME:

MEDICINE TAKING CURRENTLY:

INJURIES OR RESTRICTIONS:

MEDICAL CONDITION(S):

Consent to Treatment and Waiver of Liability Form

I, _______________________________ (parent/guardian) of _________________________________ (student/athlete), understand that LCMC Sports Medicine (Children’s Hospital, New Orleans East Hospital, Touro Infirmary, West Jeff Medical Center, and University Medical Center) provides athletic training, first aid and certain other medical services in connection with certain athletic events and programs of ____________St. Paul’s School____________ (School/Event). In case of emergency or accident on the school grounds or during any school activity involving the student designated below, which in the opinion of school authorities or personnel of LCMC Sports Medicine requires immediate medical attention, I hereby grant permission to such school authorities and LCMC Sports Medicine personnel to render medical care and to obtain the services of qualified medical personnel to treat the condition unless I am present and request otherwise or until revoked.

I also hereby release and agree to hold harmless all entities of LCMC Sports Medicine, their employees and agents, including, but not limited to, the Athletic Trainers from any and all liability in case of accident, injury, damage or other mishap in conncetion with all medical servies or athletic trainer services they provide the student.

____________________________________________________ _____________________ Student Name AND Signature Date

____________________________________________________ _____________________ Parent/Guardian Name AND Signature Date

__________________________________ Parent/Guardian Phone Number

Parental Permission to Administer Over-The-Counter (OTC) Medication to Minors

Student Name: ______________________________________ Date of Birth: ___________________________

Parent/Guardian Name: ______________________________________________________________________

Email: _________________________________________________ Cellphone: __________________________

Please list any allergies: ______________________________________________________________________

Please list any long-term medication(s) taken and the reason for taking the listed medication(s): __________________________________________________________________________________________

I, ________________________________ (Parent/Guardian Name), by below signature, hereby hold the certified athletic trainer, NOEH, and St. Paul’s School harmless in the administration of prepackaged, non-prescription OTC medications to the above listed student. I understand the certified athletic trainer will provide the medication in single dose only under a medical doctor’s oversight. No medication will be given for long term use (longer than 3 consecutive days). NOEH, St. Paul’s School and the certified athletic trainer accept no responsibility for OTC medications that are defective, either by their design or dosage recommendations, or are misused by the athlete. The misuse of medications will result in the athlete’s loss of medication privileges. OTC Medications include:

• Motrin (ibuprofen)• Tylenol (acetaminophen)• Imodium (Loperamide)• Heat Guard/Medi-Lyte (electrolytes)• TUMS (bismuth subsalicylate)• Glutose (glucose) *Only in case of identified diabetic necessity*• Benadryl (diphenhydramine HCL) *Only in case of identified allergic reaction*

Parent/Guardian Signature: _________________________________________ Date: _____________________

MEDICAL EXAMINATION A student shall annually pass a physical examination given by a licensed physician/ nurse practitioner that is in collaboration with a licensed physician or a licensed physician's assistant under the supervision of a licensed physician and complete an LHSAA Medical History Evaluation form prior to participating.

ATHLETIC PARTICIPATION/ A school shall only be required to have this form completed and signed prior to the first time PARENTAL PERMISSION FORM a student participates in LHSAA athletics at the school unless the stydenttransfers

to another member school. SUBSTANCE ABUSE/MISUSE A school shall only be required to have this form completed and signed prior to the first time a CONTRACT & CONSENT FORM student participates in LHSAA athletics at the school.

SUSPENDED AND INELIGIBLE STUDENTS Shall not participate in any interscholastic contest on any team at any school at any level.

LHSAA ELIGIBILITY RULES APPLY TO STUDENT-ATHLETES ON ALL TEAMS AT ALL LEVELS OF PLAY AT ALL LHSAA SCHOOLS

Eligibility to participate in interscholastic athletics is a privilege a student earns by meeting standards outlined on this form and other regulations and policies set by the LHSAA and the student's school. If you have questions or do not fully understand an eligibility rule, check with your child's principal, athletic director or coach. By following the intent and spirit of the rules, you can help prevent violations which may penalize the student, his/her team and/or his/her school.

ONE INELIGIBLE STUDENT MAY DISQUALIFY YOUR WHOLE TEAM - KNOW THE ELIGIBLITY RULES

PART II-PARENTAL PERMISSION

I have read and reviewed the general requirements for high school athletic eligibility on this form and have discussed these requirements with my child. I understand additional questions/explanations and specific circumstances should be directed to my child's principal, athletic director or coach.

I certify the home address listed on thjs form is my sole bona fide residence and 1b,aU will notify the school principalimmediately of any change in mx residence, since such a move may alter the eligibility status of my child. All other information given is also accurate and current.

I give my permission for the athletic trainer to release information concerning my child's injuries to the head coach/ athletic director/principal of his/her school. Additionally, I give the LHSAA or it representative(s) permission to review my child's scholastic records and all required eligibility forms however submitted by the school or myself.

If the medical status of my child changes in any significant manner after he/she passes his/her physical examination, I will notify his/her principal of the change immediately.

I hereby give my consent and approval for my child to participate in iUJJ! of the following LHSAA sports:

BASEBALL BASKETBALL BOWLING CROSS COUNTRY FOOTBALL

GOLF GYMNASTICS POWERLIFTING SOCCER SOFTBALL

SWIMMING TENNIS TRACK AND FIELD VOLLEYBALL WRESTLING

I certify all the information is correct, that I have read the summary of LHSAA eligibility rules below and I am in compliance with these standards. I also acknowledge that my child, by my signature below, has my permission to participate in interscholastic athletics during his attendance at this school. I also understand that this form shall only be completed prior to my child's first participation in any athletic contest of any sport and shall remain in effect for his/her entire athletic eligibility unless he/she transfers to another member school.

By signing below, I agree that my child and I will support and comply with all rules, policies and procedures of the LHSAA as set forth in its Handbook, including its Constitution and Bylaws.

Date: ____________ Parent's Signature:

Relationship to Student (':r (Print Name) --------------

(Principal Signature) .... 6-.... � .......... ____. ___ C_-__ �-----�-·------

Parent/Athlete Concussion Information Sheet A concussion is a type of traumatic brain injury

that changes the way the brain normally works. A

concussion is caused by bump, blow, or jolt to the

head or body that causes the head and brain to move

rapidly back and forth. Even a “ding,” “getting your

bell rung,” or what seems to be a mild bump or blow

to the head can be serious.

WHAT ARE THE SIGNS AND SYMPTOMS OF CONCUSSION?Signs and symptoms of concussion can show up right

after the injury or may not appear or be noticed until

days or weeks after the injury.

If an athlete reports one or more symptoms of

concussion listed below after a bump, blow, or jolt to

the head or body, s/he should be kept out of play the

day of the injury and until a health care professional,

experienced in evaluating for concussion, says s/he is

symptom-free and it’s OK to return to play.

Did You Know?• Most concussions occur without loss

of consciousness.

• Athletes who have, at any point in their

lives, had a concussion have an increased

risk for another concussion.

• Young children and teens are more likely to

get a concussion and take longer to recover

than adults.

SIGNS OBSERVED BY COACHING STAFF SYMPTOMS REPORTED BY ATHLETES

Appears dazed or stunned Headache or “pressure” in head

Is confused about assignment or position Nausea or vomiting

Forgets an instruction Balance problems or dizziness

Is unsure of game, score, or opponent Double or blurry vision

Moves clumsily Sensitivity to light

Answers questions slowly Sensitivity to noise

Loses consciousness (even briefly) Feeling sluggish, hazy, foggy, or groggy

Shows mood, behavior, or personality changes Concentration or memory problems

Can’t recall events prior to hit or fall Confusion

Can’t recall events after hit or fall Just not “feeling right” or “feeling down”

CONCUSSION DANGER SIGNSIn rare cases, a dangerous blood clot may form on

the brain in a person with a concussion and crowd

the brain against the skull. An athlete should receive

immediate medical attention if after a bump, blow,

or jolt to the head or body s/he exhibits any of the

following danger signs:

• One pupil larger than the other

• Is drowsy or cannot be awakened

• A headache that not only does not diminish,

but gets worse

• Weakness, numbness, or decreased coordination

• Repeated vomiting or nausea

• Slurred speech

• Convulsions or seizures

• Cannot recognize people or places

• Becomes increasingly confused, restless, or agitated

• Has unusual behavior

• Loses consciousness (even a brief loss of consciousness should be taken seriously)

WHY SHOULD AN ATHLETE REPORT THEIR SYMPTOMS?If an athlete has a concussion, his/her brain needs time

to heal. While an athlete’s brain is still healing, s/he is

much more likely to have another concussion. Repeat

concussions can increase the time it takes to recover.

In rare cases, repeat concussions in young athletes can

result in brain swelling or permanent damage to their

brain. They can even be fatal.

WHAT SHOULD YOU DO IF YOU THINK YOUR ATHLETE HAS A CONCUSSION?If you suspect that an athlete has a concussion,

remove the athlete from play and seek medical

attention. Do not try to judge the severity of the injury

yourself. Keep the athlete out of play the day of the

injury and until a health care professional, experienced

in evaluating for concussion, says s/he is symptom-free

and it’s OK to return to play.

Rest is key to helping an athlete recover from a

concussion. Exercising or activities that involve a

lot of concentration, such as studying, working on

the computer, or playing video games, may cause

concussion symptoms to reappear or get worse.

After a concussion, returning to sports and school is

a gradual process that should be carefully managed

and monitored by a health care professional.

RememberConcussions affect people differently. While

most athletes with a concussion recover

quickly and fully, some will have symptoms

that last for days, or even weeks. A more seri-

ous concussion can last for months or longer.

It’s better to miss one game than the whole season. For more information on concussions, visit: www.cdc.gov/Concussion.

Student-Athlete Name Printed Student-Athlete Signature

Parent or Legal Guardian Printed Parent or Legal Guardian Signature

ARCHDIOCESE OF NEW ORLEANS

PARENTAL/GUARDIAN COVID-19

CONSENT FORM AND LIABILITY WAIVER

Participant’s name: ________________________________________________________

Birth date: ________________________________________ Sex: __________________

Parent/Guardian’s name: ___________________________________________________

Home address: ___________________________________________________________

Home phone : ________________________ Business phone: ______________________

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health

Organization. COVID-19 is extremely contagious and as a result, social distancing is recommended.

___________________Parish/School will follow state and local standards of conduct and has put in

place reasonable preventative measures to reduce the spread of COVID-19 at its Parish/School activity

(including but not limited to summer camp). However, even though such standards will be followed

and reasonable measures put into place, Parish/School cannot guarantee that you or your child(ren)

will not become infected with COVID-19. Further, attending the Parish/School activity could increase

your risk and your child(ren)’s risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and that my child(ren)

and I may be exposed to or infected by COVID-19 by participating in the parish/school activity and

that such exposure or infection may result in personal injury, illness, permanent disability, and death. I

understand that the risk of becoming exposed to or infected by COVID-19 at _____________________

Parish/School may result from the actions, omissions, or negligence of myself and others, including,

but not limited to, Parish/School employees, volunteers, and program participants and their families.

Considering the foregoing, however, I, __________________________, grant permission for my

child,__________________, to participate in this parish activity that may require transportation to a

location away from the parish site, notwithstanding the risks associated with the COVID-19 virus and

group activities.

I confirm that there are no necessary changes to the Medical Information Consent form for my child

that I previously submitted. If there are any necessary changes, I will complete another Medical

Information Consent form.

I further agree on behalf of myself, my child named herein, and my spouse, our heirs,

successors, and assigns, to release, indemnify, hold harmless, and defend

_________________________ Parish/School and The Roman Catholic Church of the

Archdiocese of New Orleans, their members, directors, officers, employees, agents and

representatives (“indemnitees”) associated with the event arising from or in connection with

the negligent acts or omissions of the indemnitees’ in relation to prevention of the spread of

the COVID-19 virus. I SPECIFICALLY ACKNOWLEDGE AND AGREE THAT I AM

AGREEING TO DEFEND, INDEMNIFY AND HOLD HARMLESS THE INDEMNITEES’

FROM THEIR OWN NEGLIGENCE IN REGARD TO THE INDEMNITEES’ NEGLIGENT

ACTION AND/OR INACTION IN REGARD TO PROTECTION AGAINST THE COVID-

19 VIRUS.

Signature: ___________________________________________ Date: _____________________ CYO/Youth Ministry 2020

LOUISIANA HIGH SCHOOL ATHLETIC ASSOCIATION 12720 Old Hammond

Highway Baton Rouge, LA 70816

PARENTAL RELEASE AND ACKNOWLEDGEMENT OF RISK

The LOUISIANA HIGH SCHOOL ATHLETIC ASSOCIATION (LHSAA), in an effort

to continue its promotion and development of student-athletes in the State of Louisiana during

these difficult times and special circumstances, hereby offers the following release and

acknowledgement to parents as a prerequisite to participation in athletic competition, conditioning

and training. An affirming signature will be required on behalf of all student-athlete participants.

I, , the parent/legal guardian of

, do affirm and acknowledge each of the

following, free of coercion from any source or origin:

1. I am aware that my child has not obtained a physical examination and is desiring to

engage in summer athletics, conditioning and training. I further understand that an

annual physical examination is recommended for all student-athletes.

2. I am aware of no medical condition, illness, injury and/or disorder that would

preclude his/her full participation in athletic competition, training, and/or

conditioning.

3. I am not aware of and have no reason to believe that his coaches are aware of any

such medical condition, illness, injury, and/or disorder that would preclude his/her

full participation in athletic competition, training, and/or conditioning.

4. I will immediately advise the head coach and any other associated personnel should I

become aware of any condition, illness, injury, disorder, and/or other reason why my

child should not participate in athletic competition, training and/or conditioning.

Accordingly, I hereby request that St. Paul’s High School allow my child to participate

in athletic competition, training, and conditioning without restrictions, and I do hereby release

the LHSAA, school district, school, its employees, contractors, insurers, and/or assigns from

any claims arising out of the absence of an updated physical examination by a qualified

physician. I understand and acknowledge the risks associated therewith.

Signed this day of , 2020.

(Signature of Parent)

Printed Name of Parent:

Printed Name of Child: