2015-2016 FWISD Student-Athlete Medical Emergency Card ...

2015-2016

2015-2016

FWISD Student-Athlete Medical Emergency Card

PRINT OR WRITE INFORMATION CLEARLY WITH DARK INK. PLEASE DO NOT USE PENCIL OR RED INK

_____________________

____________

Student Name

FWISD student I.D. #

Current School:________________________________________

_________

______

Gender (M/F)

Grade

______

Age

Sports:_______________________________________________________

_____________________

____________

_________

_____________________

____________

___________________________

Home Address

Zip Code

Name of Primary Care Physician

Office Phone

_____/____/_____

Home Phone

Date of Birth

Hospital of Choice

__________________________________________

List any specific medical allergies, chronic illness or other medical conditions to be aware of: _____________________

List any medications student is currently taking:

Do you have Asthma? Y / N

Do you carry a rescue inhaler? Y / N Have you completed the Health Services Inhaler Form? Y / N

PARENT/GUARDIAN INFORMATION

____________________ __________ ___________________ __________

Father¡¯s Name

Last 4 digits of SS #

Mother¡¯s Name

Last 4 digits of SS #

Father¡¯s Address

City/State

Mother¡¯s Address

City/State

____________________ __________ ___________________ __________

__________

Zip Code

_________________ __________

Home Phone

_________________

Zip Code

Home Phone

______________ _________________ _____________ ________________

Cell Phone

Work Phone

Cell Phone

Work Phone

Alternate Emergency Contact

Relationship to Student

Home Phone

Other Phone

Alternate Emergency Contact

Relationship to Student

Home Phone

Other Phone

____________________ ____________ _______________ ____________

____________________ ____________ _______________ ____________

PRIMARY INSURANCE INFORMATION

My daughter/son is covered under insurance through:

________ Father

________ Mother

________ No Insurance Coverage

_______________________________

Address: _______________________

City/State: ________________

Zip Code: _______

Phone: _______________________

Policy or Group #: ____________

Name of Group Health, Accident & Hospitalization Insurance Company:

CONSENT TO EMERGENCY MEDICAL TREATMENT

I do hereby consent to such school care and treatment as may be given to said student by any physician, athletic trainer, nurse,

hospital or school representative, and 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.

I also give permission to the school district representative to use a copy of this form in case of need for emergency medical treatment

while the original is kept with my child¡¯s medical records at the school. In such a case, the parent/guardian¡¯s or alternate emergency

contact will be notified as quickly as possible.

.

______________________

Print Name ¨C Parent/Guardian

______________________

Signature ¨C Parent/Guardian

__________

Date

FORT WORTH INDEPENDENT SCHOOL DISTRICT

Health Services Department

Self- Administration of Prescribed Asthma or Anaphylaxis Medicine by Student

This form is to be completed by the parent and physician/licensed health care provider of students who are to keep

prescribed asthma or anaphylaxis medication on their person and self- administer it as prescribed.

School Name: _______________________

School Year: _____________

Parent Request

We, the undersigned parents of __________________________ request that our child be

allowed to keep the prescribed asthma or anaphylaxis medication on his/her person at all times

and self- administer it as requested by the physician.

We understand that it is the student¡¯s sole responsibility to keep the prescription medication on

his/her person. If they are misplaced or used by other students, this privilege will be revoked.

I give permission for the school nurse to consult with the above named student¡¯s

physician/licensed prescriber regarding any questions that arise with regard to the listed

medication(s) or medical condition(s) being treated by the medication(s).

___________________________

Signature of Parent(s)

________________________

Date

Physician Request

You are hereby authorized to allow __________________________ to carry the prescription

medicine on his/her person at all times.

_____________________________

Name of Medication

______________________________

Dosage and Time of Administration

Please check all that is applicable.

______ Student is knowledgeable about the medication and how to administer it.

______ Student has the skills to safely possess and use the prescribed medication.

______ Student may self-administer the medication.

All authorizations expire at the end of the school year.

________________________________________________

Signature of Physician/Licensed Health Care Provider

______________________

Telephone Number

_______________________________________________

Printed Name of Physician/Licensed Health Care Provider

_________________

Date

The student has demonstrated the skill level necessary to self-administer the prescription

medication including the use of any device required to administer the medication.

_____________________________________

Signature of School Nurse

R6/13/07

________________________

Date

2015-2016

FWISD Student-Athlete Insurance Information Policies and Procedures

Student Athlete: _________________________ , ________________________,

Last Name

First Name

_______

M.I.

The student-athletes listed above and their parents/guardians are being presented with the following

information regarding student-athlete injury care and insurance provided by the Fort Worth

Independent School District (FWISD). Please read this information carefully and thoroughly. If you have

further questions, please consult the Athletic Trainer at your high school or, for middle school studentathletes, at your feeder high school.

FWISD students who participate in UIL-sanctioned high school and middle school sports (practice, games

and travel directly to and from) and other UIL-sanctioned activities that are school-sponsored and

supervised will be covered under the District's supplemental accident-only medical insurance plan. This

insurance coverage is excess and may cover charges in excess of your own insurance policy (such as

deductibles and co-payments). If you have no other insurance, this insurance will pay first or primary.

The District¡¯s plan is a limited benefit policy and may not cover all medical bills for your child.

Parents/guardians are responsible for any charges not covered by the District¡¯s plan and for

participating in the proper bill/information submission to the claims processor. The school district,

each individual school, and any district employee or volunteer is not responsible for medical expenses or

legally liable for any injury which may result to your child while participating in a school activity.

An injury, trauma, can be defined as it pertains to the insurance policy: Trauma is defined as a physical

injury or wound that is produced by an external or internal force with sudden onset and short duration.

These injuries are covered in the policy. Injuries that result from Overuse occur with repetitive dynamics

of running, throwing, jumping and other such activities ARE NOT covered in this policy.

If your child is injured while participating in a UIL-sanctioned high school or middle school sport

(practice, games and travel directly to and from) or other UIL-sanctioned activity that requires medical

attention, notify the Athletic Trainer that the injury is a result of participation in a UIL-sanctioned activity

prior to taking your injured child to a health care provider. If the Athletic Trainer is not available,

contact the head coach or athletic coordinator or teacher responsible for supervising the activity. If

these persons are not sought out prior to visiting a health care provider, the District Plan may not pay

any benefits.

When a student-athlete does incur an injury that requires a doctor/hospital visit, an insurance claim

form must be filled out by the parent/guardian and the Athletic Trainer. The Athletic Trainer will

complete Part A of the Student Accident Claim Form and the parent/guardian must complete every line

of Part B for proper processing. All Claim Forms must be signed by a school official and a

parent/guardian prior to submission to the Claim Administrator for processing. A copy of the

completed and signed Claim Form should be kept by the parent/guardian and one returned to the

Athletic Trainer to serve as verification of the injury. The completed and signed Claim Form should be

mailed, by the parents/guardians, to the address indicated on the Claim Form or a scanned copy of the

completed and signed Claim Form may be sent electronically to email address found on the claim form.

Failure to submit a completed and signed claim form is the most frequent reason why claim payments

are delayed.

2015-2016

A Claim Form must be submitted within 90 days from the date of the injury regardless of whether you

have insurance or not. Parents/guardians should keep a copy of the Claim Form for your records and

present a copy of the Claim Form to the provider or facility. Do not rely on the provider or facility to

submit the Claim Form. Follow the instructions on the back of the Claim Form for submitting copies of

itemized bills (Form No. UB04 or HCFA 1500). Any subsequent bills received by a parent/guardian that

relates to the injury must be sent by the parent/guardians immediately to the Claim Administrator

indicating 1) name of injured person, 2) name of the school and Fort Worth ISD, and 3) the date of the

accident.

If you have other insurance, you must comply with the provisions of your primary insurance. File all bills

with your primary insurance first and forward copies of itemized bills and EOBs to the Claim

Administrator as you receive them indicating 1) name of injured person, 2) name of the school and Fort

Worth ISD, and 3) the date of the accident.

The District Plan is an accident-only plan which does not cover health issues such as heart conditions,

asthma, diabetes, hernia, etc and pre-existing conditions as defined below:

Pre-existing Condition: A disease or physical condition for which the Insured received medical advice or

treatment during the three months before the Insured¡¯s Effective Date of Coverage.

A schedule of benefits for the FWISD plan is available upon request from the Athletic Trainers at the high

schools.

Additionally, students who have an injury or any medical condition that required a doctor visit, or have a

change in their medical condition from the last athletic physical evaluation must obtain a medical

release prior to returning to any type of athletic participation. Some hospital stays and illnesses may

require documentation as well. A district wide form is available from the Athletic Trainer to prevent any

confusion that may arise from notes from doctor¡¯s offices.

Specific information and instructions will be available at preseason parent meetings, upon request, when a

claim form is issued and online at address listed on claim form.

By signing below, you are acknowledging that you have read and understand all the

information stated above. If you do not understand please get in contact with the high school

trainer who can answer your questions or direct you to someone who can. This form, along

with others, must be completed and signed prior to your son/daughter participating in any

practices or events for FWISD.

_________

Date

Revised 7/2011

_____________________________

Signature of Parent / Guardian

_____________________________

Printed Name of Parent / Guardian

SUDDEN

?CARDIAC

?ARREST

?AWARENESS

?FORM

?

Revised

?February

?2014

Name

?of

?Student:

?__________________________________________________

?

What

?is

?Sudden

?Cardiac

?Arrest?

?

! Occurs

?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

?to

?the

?brain,

?lungs

?and

?other

?organs

?of

?the

?body.

?

! The

?person

?loses

?consciousness

?(passes

?out)

?and

?has

?no

?pulse.

?

! Death

?occurs

?within

?minutes

?if

?not

?treated

?immediately.

?

What

?causes

?Sudden

?Cardiac

?Arrest?

?

! Conditions

?present

?at

?birth

?

" Inherited

?(passed

?on

?from

?parents/relatives)

?conditions

?of

?the

?heart

?muscle:

?

? Hypertrophic

?Cardiomyopathy

?¨C

?hypertrophy

?(thickening)

?of

?the

?left

?ventricle;

?the

most

?common

?cause

?of

?sudden

?cardiac

?arrest

?in

?athletes

?in

?the

?U.S.

?

? Arrhythmogenic

?Right

?Ventricular

?Cardiomyopathy

?¨C

?replacement

?of

?part

?of

?the

right

?ventricle

?by

?fat

?and

?scar;

?the

?most

?common

?cause

?of

?sudden

?cardiac

?arrest

?in

?Italy.

?

? Marfan

?Syndrome

?¨C

?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

?of

?the

?electrical

?system:

?

? Long

?QT

?Syndrome

?¨C

?abnormality

?in

?the

?ion

?channels

?(electrical

?system)

?of

?the

?heart.

? Catecholaminergic

?Polymorphic

?Ventricular

?Tachycardia

?and

?Brugada

?Syndrome

¨C other

?types

?of

?electrical

?abnormalities

?that

?are

?rare

?but

?are

?inherited.

" NonInherited

?(not

?passed

?on

?from

?the

?family,

?but

?still

?present

?at

?birth)

?conditions:

?

? Coronary

?Artery

?Abnormalities

?¨C

?abnormality

?of

?the

?blood

?vessels

?that

?supply

?blood

to

?the

?heart

?muscle.

?

?The

?second

?most

?common

?cause

?of

?sudden

?cardiac

?arrest

?in

?

athletes

?in

?the

?U.S.

?

? Aortic

?valve

?abnormalities

?¨C

?failure

?of

?the

?aortic

?valve

?(the

?valve

?between

?the

?heart

and

?the

?aorta)

?to

?develop

?properly;

?usually

?causes

?a

?loud

?heart

?murmur.

?

? Non-?©\compaction

?Cardiomyopathy

?¨C

?a

?condition

?where

?the

?heart

?muscle

?does

?not

develop

?normally.

?

? Wolff-?©\Parkinson-?©\White

?Syndrome

?¨Can

?extra

?conducting

?fiber

?is

?present

?in

?the

?heart¡¯s

electrical

?system

?and

?can

?increase

?the

?risk

?of

?arrhythmias.

?

! Conditions

?not

?present

?at

?birth

?but

?acquired

?later

?in

?life:

?

? Commotio

?Cordis

?¨C

?concussion

?of

?the

?heart

?that

?can

?occur

?from

?being

?hit

?in

?the

?chest

by

?a

?ball,

?puck,

?or

?fist.

?

? Myocarditis

?¨C

?infection/inflammation

?of

?the

?heart,

?usually

?caused

?by

?a

?virus.

? Recreational/Performance-?©\Enhancing

?drug

?use.

! Idiopathic:

?Sometimes

?the

?underlying

?cause

?of

?the

?Sudden

?Cardiac

?Arrest

?is

?unknown,

?even

?after

?

autopsy.

?

1

?

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