pisd_athletic_forms

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Dallas County Community College *

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1301

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Medicine

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Apr 3, 2024

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Palmer Athletics Parent Information Form School Year: Athletes Name: Athletes Phone #: Parents Name: Parents Phone #: Email: Address:

Ravised July 2008 THE UNIVERSITY OF TEXAS AT AUSTIN UNIVERSITY INTERSCHOLASTIC LEAGUE PHOTOGRAPHIC CONSENT AND RELEASE FORM I hereby authorize the University of Texas at Austin and the University Interscholastic League (University), and those acting in pursuant to its authority to: (a) Record my likeness and voice on a video, andio, photographic, digital, electronic or any.other medium. (b) Use my name in connection with these recordings. {c) Use, reproduce, exhibit or distribute in any medium (e.g. print publications, video tapes, CD-ROM, Internet/WWW) these recordings for any purpose that the University, and those acting pursuant to its authority, deem appropriate, including promotional or advertising efforts. I release the University and those acting pursuant to its authority from liability for any violation of any personal or proprietary right I may bave in connection with such use. I understand that all such recotdings, in whatever medium, shall remain the property of the University. I have read and fully understand the terms of this release. Name: Address: Street City State ZIP Phone: Signature: | Date: Parent/Guardian Signature (if under 18): Date:

CARDIAC ARREST (SCA) AWARENESS FORM The Basic Facts on Sudden Cardiac Arrest Website Resources: American Heart Association: www.heart.org Lead Author: Arnold Fenrich, MD and Benjamin Levine, MD Additional Reviewers: UIL Medical Advisory Committee Revised 2016 » QOccurs suddenly and often without warning. > An electrical malfunction (short- circuit) causes the bottom chambers of the heart (ventricles) to beat dangerously fast (ventricular tachycardia or fibrillation) and disrupts the pumping ability of'the heart. » The heart cannot pump blood ta the brain, lungs and other organs of the body. » The person loses consciousness (passes out) and has no pulse. $ Death cccurs within minutes if not treated immediately. heart muscle: Hypertrophic Cardiomyopathy - nypertrophy (thickening) of the left ventricle; the most commorn cause of sudden cardiac arrest in athletes in the U.S. ; Arrhythmogenic Right Ventricular Cardiomyopathy - replacement of part of the right ventricle by fat and scar; the most common cause of sudden cardiac arrestin Italy. Marfan Syndrome - a disorder of the structure of blood vessels that makes ‘them prone to rupture; often associated with very long arms and unusually flexible joints. Inherited conditions present at birth of the electrical system: Long QT Syndrome ~ abnormality in the jon channels (electrical system) of the heart. Catecholaminergic Polymorphic Ventricular Tachycardia and Brugada Syndrome - other types of electrical abriormalities that are rare but run in families. NonInherited (not passed on from the family, but still presentat birth) conditions: Coronary Artery Abnormalities - abnormality of the blood vessels that supply blood to the heart muscle. This is the second most comimon cause of sudden cardiac arrest in athletes in the U.S. Aortic valve abnormalities - failure of the aortic valve {the valve between the heart and the aorta) to develop properly; usually causes a loud heart UL Non-compaction Cardiomyopathy - a condition where the heart muscle does not develop normally. "> Fainting/blackouts (especially Siidde during exercise) > Dizziness » Unusual fatigue/weakness » Chestpain » Shortness of breath » Nausea/vomiting » Palpitations (heart is beating unusually fast.or skipping beats) » Pamily history of sudden cardiac arrestatage < 50 ANY of these symptoms and warning signs that oceur while exercising may necessitate further evaluation from your physician before returning to practice or @ game. Idiopathic: Sometimes the underlying T1m is cr cl' Wolff-Parkinson-White Syndrome - response is vital an extra conducting fiber is presentin » CALL 911 the heart's electrical system and can > Begin CPR increase the risk of arrhythmias. » Use an Automated External Conditions not present at birth but Defibrillator (ARD) acquired later in life: Thatara e taiscre Commotio Cordis - concussion of the : heart that can occur from being hitin the chest by a ball, puck, or fist. The American Heart Association recommends a pre-participation history and physical including 14 impoertant cardiac elements, The UIL Pre-Participation Physical Evaluation - Medical History form includes ALL 14 of these important cardiac elements and is mandatory annually. Myocarditis - infection or inflammation of the heart, usually caused by a virus. Recreational/Performance- Enhancing drug use. cause of the Sudden Cardiac Arrestis unknown, even after autopsy.

requires use of the specific Preparticipation Medical History form on a yearly basis. This process begins with the parents and. student-athletes answering questions about symptoms during exercise (such as chest pain, dizziness, fainting; palpitations or shortness of breath); and guestions about family health history. Itis important to know if any family member died suddenly during physical actvity or during a seizure. Itis also {mportantto know if anyone in the family under the age of 50 had an unexplained sudden death suchas drowning or car accidents. This information must be provided annually Additio g using an electrocardiogram (ECG) and/or an echocardiogram (Echo) is readily available to all athletes from their personal physicians, but is not mandatory, and is generally not recommended by either the American Heart Association (AHA) or the American College of Cardiology (ACC). Limitations of additional scteening include the possibility (~10%) of “false positives”, which leads to unnecessary stress for the student and parent or guardian as well as unnecessary restriction from athletic participation. There is also a possibility of “false negatives”, since not all cardiac conditions will be identified by additional screening. because it is essential to identify those at g risk for sudden cardiac death. The University Interscholastic League requires the Preparticipation Physical Examination form prior to junior high athletic participation and again prior to the 15tand 3 years of high school participation. The required physical exam includes measurement of blood pressure ard a careful listening examination of the heart, especially for murmurs and rhythm abnormalites. If there are no warning signs reported on the health history and no abnormalities discovered on exam, no additional evaluation or testing is recommended for cardiac issues/concerns. If a qualified examiner has concerns, a referral to a child heart spectalist, a pediatric cardiclogist, is recommended. This specialist may perform a more thorough evaluation, includingan - electrocardiogram (ECG), whichisa graph of the electrical activity of the- heart. An echocardiogram, which is an ultrasound test to allow for direct visualization of the heart structure, may also be done. The specialist may also order a treadmill exercise test and/or a monitor-to enable a longer recording of the heart rhythm. None of the testing is invasive or uncomfortable. | SR by I prev i The only effective treatment for A prope ' Physical Evaluation - Medical History) should find many, but not all, conditions that could cause sudden death in the athlete, This is because some diseases are difficult to uncover and may only develop later in life, Others can develop following a normal screening evaluation, such as an infection of the heart muscle | from a virus. This is why a medical history and a review of the family health history need to be performed on a yearly basis. With proper screening and evaluation, most cases can be identified and prevented. yent ventricilar fibrillation is immediate use of an automated external defibrillator 8 (AED). An AED can restore the heart back into a normal rhythm. An AED is also life-saving for ventricular fbrillation caused by a blow to the chest over the heart (commotio cordis). Texas Senate Bill 7 requires that at any school sponsored athletic event or team practice in Texas public high schools the following must be available: > An AED isin an unlocked location on school property within a reasonable proximity to the athletic field or gymmnasiom All coaches, athletic trainers, PE teacher, nurses, band directors and cheerleader sponsors are certified in cardiopulmonary resuscitation (CPBR) and the use of the AED. x> Parent/Guardiah Name {Print) Fach school has a developed safety procedure to respond to a medical emergency involving a cardiac arrest. The American Academy of Pediatrics recommends the AED should be placed in a central location that is accessible and ideally no morethana1to 11 /2 minute walk from any location and that a call is made to activate 911 emergency system while the AED is being retrieved. FArg EXCALAAL K R 1 certify that I have read and understand the above information. q Parent/Guardian Signature Date Student Signature .Student Name (Print) Date

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