preparticipation physical evaluation --medical history revised 1-11-06

Transcripción

Western Hills High School Band
www.whhscougarband.org | 817.815.6080 | 3600 Boston Avenue, Fort Worth, Texas 76116
Band Registration Packet 2015 – 2016
Greetings Cougar Band!!
First, I would like to introduce myself. My name is Phillip Cadenhead and I am very excited about joining the
cougar band this upcoming year! I am genuinely looking forward to meeting each of you and getting started to
make this year dynamic and memorable. I have enjoyed meeting with the staff and leadership and cannot
wait to become more familiar with the Cougar Band!
Enclosed in this letter, you will find all the necessary forms and information you will need for participating in
marching band. It is very important for everyone to be at every rehearsal as we begin preparations for the
2015 Marching Season. Please email me directly at [email protected] with any foreseeable
conflicts as soon as possible.
Required forms and Registration
The Physical (FWISD Physician & Parents Certificate for Participation in Marching Band Form) must be on
file with the Band Director before the student will be allowed to participate in any rehearsal. Please send your
student with the completed form on the first day of their summer rehearsal.
Checklist of Paperwork and Items to bring to Registration on Friday, July 31st from 5:30 – 8:30:
 FWISD Physician & Parents Certificate for Participation in Marching Band Form (Physical Form)
 FWISD Media Release Form
 Parent Permission, Release, and Indemnity Trips Form
 Parental Form and Release from Claims
 Travel Parent Release Form
 Medical Information Form
 Volunteer Background Check Form – available online at http://volunteer.fwisd.org
 Volunteer Computerized History (CCH) Verification Form
 UIL 8 Hour Rule Acknowledgement Form
 Band Fee Deposit of $200
 Bring any item you wish not to replace this season such as camelbak, shoes, compression shirt, etc.
 All School-owned instruments currently checked out.
 Pictures will be taken during Registration
Dress Code for Summer Band
Students must wear appropriate clothing for all summer band rehearsals. Failure to dress appropriately
presents a health hazard and students will be sent home to acquire appropriate clothing.
What to Wear: Athletic Shoes, Loose-fitting, light-colored shirt, Shorts, Sunglasses and Hat (not to be worn in
the building), Sunscreen, Camelbak
What NOT to Wear: Black, Tank-tops, Shirts with inappropriate slogans or words, clothing in violation with
school dress code
Director Contact Information
Phillip Cadenhead
[email protected]
Director of Bands
Kyle Harvison
[email protected]
Associate Director of Bands
Spencer Crawford
[email protected]
Director of Percussion
Band Fee Information
Outlined below you will find the band fee structure for the year. Please plan to make a deposit of $200 by the
date of Registration, July 31st 2015. To make check payments prior to Registration, please send them payable to
Western Hills Area Band Boosters at PO Box 122601, Fort Worth, TX 76121. You may also pay with credit card,
debit card, or with your PayPal account on the band website, www.whhscougarband.org.
We want every student to have a chance to participate regardless of the family’s financial situation. Please
contact me at [email protected] or call me at (817) 815-6080 to discuss possible payment plans if
needed.
Winds
Base Fees (All Students)
Beverages/Snacks at Games
Dinner at Games/Contests
Show T-Shirt
Band Banquet Tickets
Staff Fees
Notebooks/Supplies
Uniform Cleaning Fee
Gloves/Wristbands
Equipment/Prop Maintenance Fee
New Student/Replacement Items
Band Polo
Compression Shirt
Camelbak
Black MTX Shoes
Guard Travel Bag
Guard Flag Bag
Instrument Specific Items
Solo and Ensemble Entry
Solo and Ensemble Accompanist (Winds Only)
School-Owned Instrument Rental Fee
Stick, Mallet Head Fee (Perc. Only)
Marching/Winterguard Uniform (Guard Only)
TOTAL (All Items)
Percussion Colorguard
$15.00
$72.00
$20.00
$30.00
$130.00
$8.00
$30.00
$8.00
$10.00
$15.00
$72.00
$20.00
$30.00
$150.00
$8.00
$30.00
$5.00
$10.00
$15.00
$72.00
$20.00
$30.00
$200.00
$8.00
$30.00
$15.00
$20.00
$25.00
$18.00
$40.00
$40.00
$25.00
$18.00
$40.00
$40.00
$25.00
$18.00
$40.00
$20.00
$20.00
$10.00
$30.00
$60.00
$10.00
$100.00
$556.00
$573.00
$250.00
$783.00
2015 WHHS Summer Band
Summer Rehearsal Schedule 2015
Mon
Tue
July 27
Wed
28
29
Thu
30
Fri
31
Sat
Aug 1
Student Leadership & Freshmen 9-Noon
Registration
5:30-8:30*
Student Leadership 9:00-4:00
3
4
5
6
7
8
DCI @ Ridgemar
5:30PM $18
Summer Band 7:30- 4:00
10
11
12
13
Summer Band
7:30- 4:00
17
Car Wash
14
15
20
21
22
27
28
29
4
5
Rehearsal 5:30-9
18
19
Rehearsal 5:30-9
24 First day of
25
26
school!
Rehearsal 7-8:15 AM
Game v.
Burleson @ Clark
7pm
Rehearsal 6-8:30
31
Sept 1
2
3
Rehearsal 7-8:15 AM
Rehearsal 6-8:30
Calendar Details
July 31st Band Registration Times:
5:30 Seniors & Juniors
6:30 Sophomores
7:30 Freshmen
Summer Band Day Itinerary:
7:30 – 11:30 Rehearsal
11:30- 12:30 Lunch
12:30- 4:00 Rehearsal
Detailed Sectional Schedule and Performance Schedule will be released during summer band!
A1
School Year:
2014-2015
Grade (circle one): 9
10
11
12
FORT WORTH INDEPENDENT SCHOOL DISTRICT
UNIVERSITY INTERSCHOLASTIC LEAGUE
PHYSICIAN’S & PARENT CERTIFICATE FOR PARTICIPATION IN MARCHING BAND
Attention: This form MUST be filled out COMPLETELY, signed by either a Physician, a Physician Assistant, licensed by a State Board of
Physician Assistant Examiners, or a Registered Nurse recognized as an Advanced Practice Nurse by the Board of Nurse Examiners, or a
Doctor of Chiropractic, signed by both the student and parent/guardian, and on file with the Band Director BEFORE the student will be
allowed to participate in any rehearsal, tryout, practice session, performance, contest, or camp for band, colorguard and drill team.
--------------------------------------------------------------------------------------------------Name: ________________________________________________
D.O.B. ____________________________
Sex: M / F
Parent/Guardian Name: ____________________________________________ Phone # (_______)______________________________
Address: ______________________________________________________________________________________________________
(Street Address, City, State, Zip Code)
Mom: Home # (
__ )
Work # (
__)
____ Other # (
___)
____
Dad: Home # (
__ )
Work # (
__)
____ Other # (
___)
____
Emergency Contact: __________________________________________________ Phone: ________________________________
School: _______________________________________________________________________________________________________
Program / Activity: ______________________________________________________________________________________________
School Year:
2014-2015
Grade (circle one): 9
10
11
12
FORT WORTH ISD
EMERGENCY CARD / CONSENT FOR TREATMENT
Name: ________________________________________________
D.O.B. ____________________________
Sex: M / F
Parent/Guardian Name: ____________________________________________ Phone # (_______)______________________________
Address: ______________________________________________________________________________________________________
(Street Address, City, State, Zip Code)
Mom: Home # (
__ )
Work # (
__)
____ Other # (
___)
____
___
Dad: Home # (
__ )
Work # (
__)
____ Other # (
___)
____
___
In case of emergency and parent / guardian cannot be reached, please contact:
Name: ______________________________________________________________ Phone ___________________________________
In the event that the parents / guardians of the above-named student cannot be contacted, I hereby accept the emergency services of a team
physician, athletic trainer, band director or other available personnel and hereby authorize the band director, athletic trainer, coach, or other
school officials to sign such papers as may be required to obtain immediate medical attention necessary for the welfare and safety of such student.
I do hereby agree to indemnify and hold harmless the school and any school or hospital representative from any claim by any person on
account of such care and treatment of said student.
__________________
Date
__________________________________________
Student Signature
________________________________________
Parent / Legal Guardian Signature
A2
NAME: _______________________________________________
D.O.B. ____________________________
Sex: M / F
REQUIRED INSURANCE INFORMATION
________
NO insurance provider coverage at all
________
Personal insurance provider coverage:
Insurance Company: _________________________________________________
Phone # of Insurance Company: ________________________________________
Name of Insured: ____________________________________________________
Group Policy # ______________________________________________________
We further acknowledge that, pursuant to the Texas Tort Claims Act, the Fort Worth Independent School
District cannot be held liable for any injuries sustained in practice or interscholastic competition, and we
therefore agree that no legal action may be brought against the District from any such injuries.
__________________
__________________________________________
Date
Student Signature
________________________________________
MEDICAL HISTORY (please respond to ALL questions)
Allergies?
Yes / No
Allergies to medications?
Yes / No
Asthma?
Yes / No
Contacts/Glasses?
Yes / No
Diabetes?
Yes / No
Epilepsy?
Yes / No
Heart Trouble?
Yes / No
Please explain all “Yes” answers and list all drug allergies and/or medications taken regularly:
I hereby certify that all the above information is true to the best of my knowledge.
__________________
Date
__________________________________________
Student Signature
________________________________________
PREPARTICIPATION PHYSICAL EVALUATION --MEDICAL HISTORY
REVISED 1-6-09
A3
This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) and student in order for the student to participate in Marching Band and
Colorguard activities. These questions are designed to determine if the student has developed any condition, which would make it hazardous to participate in such events.
Student's Name: ____________________________________________ Sex ___________Age _________________Date of Birth ___________________________
Address_______________________________________________________________________________________Phone_________________________________
Grade ______________________________________ School__________________________________________________________________________________
Personal Physician_____________________________________________________________________Phone__________________________________________
Emergency contact: Name _______________________________ Relationship__________________ Phone (H)__________________(W) ____________________
Explain “Yes” answers in the box below**. Circle questions you don’t know the answers to. Any Yes answer to questions 1, 2, 3, 4, 5, or 6 requires further medical evaluation which
may include a physical examination. Written clearance from a physician, physician assistant, chiropractor, or nurse practitioner is required before any participation in UIL practices,
performance, or competition.
Yes No
1. Have you had a medical illness or injury since your last check up
or sports physical?
2. Have you been hospitalized overnight in the past year?
Have you ever had surgery?
3. Have you ever passed out during or after exercise?
Do you get tired more quickly than your friends do during
exercise?
Have you ever had a racing of your heart or skipped heartbeats
Have you had high blood pressure or high cholesterol?
Have you ever been told you have a hear murmur?
Has any family member or relative died of heart problems or of
sudden unexpected death before age 50?
Has any family member been diagnosed with enlarged heart,
(dilated cardiomyopathy), hypertrophic cardiomyopathy, long
QT syndrome or other ion channelpathy (Brugada syndrome, etc.),
Marfan’s syndrome, or abnormal heart rhytm?
Have you had a severe viral infection (for example, myocarditis
or mononucleosis) within the last month?
Has a physician ever denied or restricted your participation in
sports for any heart problems?
4. Have you ever had a head injury or concussion?
Have you ever been knocked out, become unconscious, or lost
your memory?
If yes, how many
When was the last
times?
_______ concussion?
________________
How severe was each one? (Explain below)
Have you ever had a seizure?
Do you have frequent or severe headaches?
Have you ever had numbness or tingling in your arms, hands,
legs, or feet?
Have you ever had a stinger, burner, or pinched nerve?
5. Are you missing any paired organs?
6. Are you under a doctor’s care?
7. Are you currently taking any prescription or non-prescription
(over-the-counter) medication or pills or using an inhaler?
8. Do you have any allergies (for example, to pollen, medicine,
food, or stinging to insects)?
9. Have you ever been dizzy during or after exercise?
10. Do you have any current skin problems (for example, itching,
rashes, acne, warts, fungus, or blisters)?
11. Have you ever become ill from exercising in the heat?
12. Have you had any problems with your eyes or vision?
Yes No
13. Have you ever gotten unexpectedly short of breath with
exercise?
Do you have asthma?
Do you have seasonal allergies that require medical treatment?
14. Do you have any special protective or corrective equipment or
devices that aren’t usually used for your sport or position (for
example, knee brace, special neck roll, foot orthotics, retainer
on your teeth, hearing aid)?
15. Have your ever had a sprain, strain, or swelling after injury?
Have you broken or fractured any bones or dislocated any joints?
Have you had any other problems with pain or swelling in
muscles, tendons, bones, or joints?
If yes, check appropriate box and explain below.
Head
Elbow
Hip
Neck
Forearm
Thigh
Back
Wrist
Knee
Chest
Hand
Shin/Calf
Upper Arm
Finger
Ankle
Shoulder
Foot
16. Do you want to weigh more or less than you do now?
Do you lose weight regularly to meet weight requirements for your
sport?
17. Do you feel stressed out?
18. Have you ever been diagnosed with or treated for sickle cell trait
or sickle cell disease?
Females Only:
19. When was your first menstrual period?
_______________
When was your most recent menstrual period?
_______________
How much time do you usually have from the start of one
period to the start of another?
_______________
How many periods have you had in the last year?
_______________
__________________________________________________________
An individual answering in the affirmative to any question relating to a possible
cardiovascular health issue (question three above), as identified on the form, should be
restricted from further participation until the individual is examined and cleared by a
physician, physician assistant, chiropractor, or nurse practitioner.
___________________________________________________________
**EXPLAIN ‘YES’ ANSWERS IN THE BOX BELOW (attach another sheet if necessary):
____________________________________________________
____________________________________________________
____________________________________________________
_______________________________________
It is understood that there is always the possibility of an accident during practice, performance, or competition. Neither the University Interscholastic League nor the
high school assumes any responsibility in case an accident occurs.
If, in the judgment of any representative of the school, the above student should need immediate, care and treatment as a result of any injury or sickness, I do herby
request, authorize, and consent to such care and treatment as may be given said student by any physician, band director, athletic trainer, nurse, or school representative. I
do herby agree to indemnify and save harmless the school and any school or hospital representative from any claim by any person on account of such care and treatment
of said student
If, between this date and the beginning of practice, performance or competition, any illness or injury should occur that may limit this student's participation, I
agree to notify the school authorities of such illness or injury.
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Failure to provide truthful responses could
subject the student in question to penalties determined by the UIL
Student Signature: ___________________________________ Parent/Guardian Signature: ___________________________________ Date: ____________
THIS FORM MUST BE ON FILE PRIOR TO PARTICIPATION IN ANY PRACTICE, CONTEST, OR PERFORMANCE, BEFORE, DURING OR AFTER SCHOOL.
For School Use Only:
This Medical History Form was reviewed by: Printed Name __________________________Date__________________Signature____________________________
A4
PREPARTICIPATION PHYSICAL EVALUATION --PHYSICAL EXAMINATION
Student's Name_________________________________
Height ______
Weight _______
Sex________
% Body fat (optional) _______
Age________
Date of Birth_________________________
Pulse __________ BP____/____ (____/____, ____/____)
brachial blood pressure while sitting
Vision R 20/______ L 20/______
Corrected:
Y N
Pupils: Equal ______ Unequal ______
As a minimum requirement, this Physical Examination Form must be completed prior to initial participation in any Marching
Band or Colorguard activities, and annually thereafter. It must be completed if there are yes answers to specific questions on the
student’s MEDICAL HISTORY FORM on the reverse side. *Local district poly may require an annual physical exam.
NORMAL
ABNORMAL FINDINGS
INITIALS*
MEDICAL
Appearance
Eyes/Ears/Nose/Throat
Lymph Nodes
Heart-Auscultation of the heart in the
supine position.
standing position.
Heart-Lower extremity pulses
Pulses
Lungs
Abdomen
Genitalia (males only)
Skin
Marfan’s stigmata (arachnodactyly,
pectus excavatum, joint
hypermobility, scoliosis)
MUSCULOSKELETAL
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand
Hip/Thigh
Knee
Leg/Ankle
Foot
*station-based examination only
CLEARANCE
Cleared
Cleared after completing evaluation/rehabilitation for:____________________________________________________________
_______________________________________________________________________________________________________
Not cleared for: ________________________________________ Reason:___________________________________________
Recommendations:___________________________________________________________________________________________
The following information must be filled in and signed by either a Physician, a Physician Assistant licensed by a State
Board of Physician Assistant Examiners, a Registered Nurse recognized as an Advanced Practice Nurse by the Board of
Nurse Examiners, or a Doctor of Chiropractic. Examination forms signed by any other health care practitioner will not be
accepted.
Name (print/type) ___________________________________________ Date of Examination: _____________________
Address: ___________________________________________________Phone Number __________________________
Signature: __________________________________________________________________________________________
Must be completed before a student participates in any practice, performance or competition, before, during or after school.
(both in-season and out-of-season) or any other marching band or colorguard activity of any kind.
A1
Año escolar:
2014-2015
Grado (ponga uno en un círculo): 9
10
11
12
DISTRITO ESCOLAR INDEPENDIENTE DE FORT WORTH
LIGA INTERESCOLAR UNIVERSITARIA
CERTIFICADO DE MÉDICO Y PADRES PARA PARTICIPACIÓN EN BANDA DE MARCHA
Atención: Este formulario DEBE estar lleno COMPLETAMENTE, firmado ya sea por el médico, asistente licenciado por la mesa estatal o una
enfermera certificada reconocida como enfermera en práctica avanzada por la mesa examinadora de enfermeras o un doctor en quiropráctica, firmado
por el estudiante y el padre/guardián y archivado con el director de banda ANTES de que se le permita al estudiante participar en cualquier ensayo,
concurso, sesión de práctica, actuación, evento o programa para banda, abanderados y equipo de actuación.
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Nombre: ____________________________________________________ F.D.N. _______________________________ Sexo: M / F
Nombre de padre/guardián: __________________________________________ # de teléfono (_______)_____________________________
Dirección: ________________________________________________________________________________________________________
(Dirección de calle, Ciudad, Estado, Zona postal)
Madre: # casa (
__ )
# trabajo (
__)
____ Otro # (
___)
_______ ____
Padre: # casa (
__ )
# trabajo (
__)
____ Otro # (
___)
____
Contacto en emergencia: _______________________________________________ Teléfono: _____________________________________
Escuela: __________________________________________________________________________________________________________
Programa / Actividad: _______________________________________________________________________________________________
Año escolar:
2014-2015
Grado (ponga uno en un círculo): 9
10
11
12
FORT WORTH ISD
TARJETA DE EMERGENCIA / CONSENTIMIENTO DE TRATAMIENTO
Nombre: ________________________________________________
F.D.N. ____________________________
Sexo: M / F
Nombre de padre/guardián: __________________________________________ # de teléfono (_______)_____________________________
Dirección: ________________________________________________________________________________________________________
(Dirección de calle, Ciudad, Estado, Zona postal)
Madre: # casa (
__ )
# trabajo (
__)
____ Otro # (
___)
Padre: # casa (
__ )
# trabajo (
__)
____ Otro # (
___)
________
____
____________
En caso de emergencia y que no se pueda contactar a padre/guardián, por favor contactar a:
Nombre: ____________________________________________________________ Teléfono___________________________________
En caso que no se pueda contactar a los padres/guardianes del estudiante nombrado arriba, acepto los servicios de emergencia del médico del
equipo, entrenador atlético, director de banda u otro personal disponible, entrenador u otros oficiales escolares para firmar los papeles requeridos
con el fin de obtener atención médica inmediata necesaria para el bienestar y seguridad de cada estudiante. Estoy de acuerdo en indemnizar y
librar de responsabilidad a la escuela y a cualquier representante escolar o de hospital de cualquier reclamo de cualquier persona en
relación con dicho tratamiento del estudiante en cuestión.
__________________
Fecha
__________________________________________
Firma de estudiante
________________________________________
Firma de padre/guardián legal
A2
NOMBRE: _______________________________________________
F.D.N. ____________________________
Sexo: M / F
INFORMACIÓN DE SEGURO REQUERIDA
________
NO tiene seguro de ningún tipo
________
Cobertura de seguro personal:
Compañía aseguradora: __________________________________________________________
Número telefónico de compañía aseguradora: ________________________________________
Nombre de asegurado: __________________________________________________________
# de póliza de grupo ____________________________________________________________
Además entendemos que según el Acto de demandas de agravios de Texas, no se le puede hacer responsable al
distrito escolar independiente de Fort Worth por ninguna herida recibida en práctica o competencia interescolar,
y nosotros, por consiguiente, estamos de acuerdo en que no se presentará ninguna acción legal contra el distrito
por dichas heridas.
__________________
Fecha
__________________________________________
________________________________________
Firma de estudiante
HISTORIAL MÉDICO (por favor responda a TODAS las preguntas)
Alergias?
Sí / No
Alergias a medicinas?
Sí / No
Asma?
Sí / No
Contactos/lentes?
Sí / No
Diabetes?
Sí / No
Epilepsia?
Sí / No
Problemas con el corazón?
Sí / No
Por favor explique todas las respuestas “Sí” e indique todas las alergias a medicinas y/o medicinas tomadas regularmente:
Certifico que toda la información de arriba es verdadera en cuanto yo tengo conocimiento.
__________________
Fecha
______________________________________
Firma de estudiante
_____________________________________
A3
EVALUACIÓN FÍSICA INICIAL PARA PARTICIPAR EN ACTIVIDADES – HISTORIAL MÉDICO
REVISADO 6-1-09
Este FORMULARIO de HISTORIAL MÉDICO tiene que ser completado anualmente por un padre (o guardián) y el estudiante para que el estudiante pueda participar
en la Banda de Desfile y en el grupo de Abanderados de la Banda. Estas preguntas están diseñadas para determinar si el estudiante ha desarrollado alguna condición con
la cual sería peligroso participar en estas actividades.
Nombre del estudiante: ___________________________________ Sexo ________ Edad _________Fecha de nacimiento ___________________________
Dirección_____________________________________________________________________________Numero de teléfono________________________________
Grado _________________________________ Escuela__________________________________________________________________________________
Médico de familia___________________________________________________________Numero de teléfono__________________________________________
Contacto de emergencia: Nombre _______________________ Relación con el estudiante____________ Teléfono (Casa)_____________(Trabajo) ________________
Explique las respuestas que conteste “Si” en la caja en la parte de abajo de esta hoja.**. Circule las preguntas a las cuales no sabe las respuestas. Si contestó “si” en la pregunta 1,
2, 3, 4, 5, o 6 esto requiere evaluación medica adicional, la que debe incluir un examen físico. Un permiso escrito del doctor, asistente del doctor, quiropráctico o enfermera es requerido
antes de poder participar en las prácticas de UIL, presentaciones, o competencias.
Si No
1. ¿Has tenido una enfermedad o te has lastimado desde tu última
visita al doctor?
2. ¿Has pasado una noche hospitalizado en el último año?
¿Has tenido alguna cirugía?
3.¿Te has desmayado durante o después de hacer ejercicio?
¿Te cansas más rápido que tus amigos al hacer ejercicio?
¿Has tenido palpitaciones inconsistentes del corazón?
¿Has tenido la presión alta o el colesterol alto?
¿Te han dicho que tienes un murmullo del corazón?
¿Algún miembro de tu familia se ha muerto de problemas del
corazón o inesperadamente antes de los 50 años?
¿A algún miembro de tu familia le han diagnosticado
un corazón dilatado (cardiomiopatía dilatada), cardiomiopatía
hipertrófica, síndrome QT u otra canalpatía iónica (síndrome
Brugada, etc) síndrome Marfan o ritmos anormales del corazón?
¿Has tenido una infección viral grave, por ejemplo, miocarditis
o mononucleosis) en el último mes?
¿Te ha negado o restringido un doctor participación en deportes
por problemas del corazón?
4. ¿Alguna vez te has lastimado la cabeza o tenido una contusión?
¿Te has golpeado fuerte, desmayado o perdido la memoria?
¿Si contestaste que sí, cuántas veces? ________________
¿Cuándo fue la última contusión? __________________
¿Qué tan grave fue cada una? (Explique debajo)
¿Alguna vez has tenido un ataque?
¿Tienes dolores de cabeza frecuentes o graves?
¿Alguna vez te has entumecido o tenido hormigueo en tus brazos,
manos, piernas o pies?
¿Has tenido picor, quemazón o un nervio pinchado?
5. ¿Te falta algún órgano que tenga pareja?
6. ¿Estás bajo el cuidado de un doctor?
7. ¿Estás tomando medicinas recetadas o sin receta,
o pastillas o usando un inhalador?
8. ¿Tienes alguna alergia (por ejemplo, al polen, medicina,
comida o picadas de insectos)?
9. ¿Te has mareado alguna vez durante o después de hacer ejercicio?
10. ¿Tienes problemas de la piel (por ejemplo, picazón,
erupciones, acné, verrugas, hongos o ampollas)?
11. ¿Te has enfermado por hacer ejercicio cuando hace calor?
12. ¿Has tenido problemas con tus ojos o con tu vista?
Si No
13. ¿Alguna vez te ha sido difícil respirar mientras hacías ejercicio?
¿Tienes asma?
¿Tienes alergias que requieren tratamiento medico?
14. ¿Tienes algún tipo de equipo especial para proteger o corregir que
no se suele usar para tu deporte o posición (por ejemplo protector
de rodilla, protector de cuello, plantillas, corrector de dientes,
audífono)?
15. ¿Has tenido una torcedura, lastimadura o inflamación con una lesión?
¿Te has roto o fracturado algún hueso o dislocado las coyunturas?
¿Has tenido cualquier otro problema con los músculos, tendones,
huesos o coyunturas?
Si contestaste sí marca la caja apropiada y explica debajo.
Cabeza
Codo
Cadera
Cuello
Antebrazo
Muslo
Espalda
Muñeca
Rodilla
Pecho
Mano
Espinilla/Pantorrilla
Brazo
Dedo
Tobillo
Hombro
Pie
16. ¿Quieres pesar más o menos de lo que pesas?
¿Pierdes peso regularmente para satisfacer los requisitos
de peso de tu deporte?
17. ¿Te sientes estresado?
18. ¿Te han diagnosticado o tratado para la condición de célula falciforme?
Sólo para mujeres:
19. ¿Cuándo fue tu primera menstruación? _______________
¿Cuándo fue la menstruación más reciente? _______________
¿Cuánto tiempo transcurre entre el principio de una menstruación a otra? _________
¿Cuántas menstruaciones tuviste el año pasado? _______________
____________________________________________________
Un individuo que contesta afirmativamente a cualquier pregunta sobre la salud del
corazón (pregunta tres), como identificado en el formulario, debe ser restringido de
participar hasta que el individuo haya sido examinado por un doctor, asistente de doctor,
quiropráctico, o enfermera, y le hayan dado permiso de participar.
___________________________________________________________
**EXPLICA LAS RESPUESTAS QUE CONESTASTES ‘SI’ EN LA CAJA DEBAJO
(Adjunte otra hoja si es necesario):
____________________________________________________
____________________________________________________
____________________________________________________
Se entiende que siempre hay la posibilidad de un accidente durante la práctica, programa o competencia. Ni la Liga Interescolar Universitaria ni la escuela preparatoria
asume ninguna responsabilidad en caso de que ocurra un accidente.
Si un representante de la escuela cree que el susodicho estudiante necesita cuidado y tratamiento inmediato como resultado de cualquier lesión o enfermedad, por la
presente yo pido, autorizo y doy mi consentimiento para que cualquier doctor, el director de la banda, el entrenador deportivo, la enfermera o el representante de la
escuela le proporcionen el cuidado y tratamiento necesario. Por lo que acepto indemnizar y librar de cargos a la escuela, o a cualquier representante de la misma o
representante del hospital de cualquier reclamo por cualquier persona como consecuencia del tratamiento del susodicho estudiante.
Si ocurre cualquier enfermedad o lesión que pueda limitar la participación del estudiante entre esta fecha y el inicio de la práctica, programa ocompetencia me
comprometo a notificar a los representantes de la escuela de dicha enfermedad o lesión.
Declaro que de acuerdo con mi conocimiento, mis respuestas a las preguntas anteriores están completas y correctas. Si no se proporcionan respuestas
verdaderas el estudiante podría ser sancionado con castigos determinados por la UIL.
Firma del estudiante: ____________________________ Firma de la madre, padre o guardián: ______________________________ Fecha: ____________
ESTE DOCUMENTO DEBE ESTAR EN EL EXPEDIENTE, PREVIO A CUALQUIER PRÁCTICA, COMPETENCIA O PROGRAMA ANTES, DURANTE O DESPUÉS
DE LA ESCUELA.
Para el uso de la escuela solamente:
Este historial médico fue revisado por: Nombre __________________________Fecha__________________Firma ____________________________
A4
PREPARTICIPATION PHYSICAL EVALUATION --PHYSICAL EXAMINATION
Student's Name_________________________________
Height ______
Weight _______
Sex________
% Body fat (optional) _______
Age________
Date of Birth_________________________
Pulse __________ BP____/____ (____/____, ____/____)
brachial blood pressure while sitting
Vision R 20/______ L 20/______
Corrected:
Y N
Pupils: Equal ______ Unequal ______
As a minimum requirement, this Physical Examination Form must be completed prior to initial participation in any Marching
Band or Colorguard activities, and annually thereafter. It must be completed if there are yes answers to specific questions on the
student’s MEDICAL HISTORY FORM on the reverse side. *Local district poly may require an annual physical exam.
NORMAL
ABNORMAL FINDINGS
INITIALS*
MEDICAL
Appearance
Eyes/Ears/Nose/Throat
Lymph Nodes
supine position.
standing position.
Heart-Lower extremity pulses
Pulses
Lungs
Abdomen
Genitalia (males only)
Skin
Marfan’s stigmata (arachnodactyly,
pectus excavatum, joint
hypermobility, scoliosis)
MUSCULOSKELETAL
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand
Hip/Thigh
Knee
Leg/Ankle
Foot
*station-based examination only
CLEARANCE
Cleared
Cleared after completing evaluation/rehabilitation for:____________________________________________________________
_______________________________________________________________________________________________________
Not cleared for: ________________________________________ Reason:___________________________________________
Recommendations:___________________________________________________________________________________________
The following information must be filled in and signed by either a Physician, a Physician Assistant licensed by a State
Board of Physician Assistant Examiners, a Registered Nurse recognized as an Advanced Practice Nurse by the Board of
Nurse Examiners, or a Doctor of Chiropractic. Examination forms signed by any other health care practitioner will not be
accepted.
Name (print/type) ___________________________________________ Date of Examination: _____________________
Address: ___________________________________________________Phone Number __________________________
Signature: __________________________________________________________________________________________
Must be completed before a student participates in any practice, performance or competition, before, during or after school.
(both in-season and out-of-season) or any other marching band or colorguard activity of any kind.
B
Communications Department
100 N. University Dr., Ste. 258 Fort Worth, Texas 76107
OFFICE 817.814.1930 FAX 817.814.1935
www.fwisd.org
Dear Parent or Guardian,
Please return this form along with other paperwork to your school by tomorrow. Your child’s homeroom teacher or principal
will keep this permission slip on file by for special events that may include the following:
1) FWISD staff, and/or
2) News media (television, newspaper, radio, magazines)
In conjunction with programs in the Fort Worth Independent School District for any lawful purpose, I understand that by my
signed permission on this form I agree without further notice to me:
• That FWISD pictures may be reproduced, copyright, broadcast, telecast or cablecast, published or used in district materials
(including the Web site) for distribution to school employees and the public.
• to hold harmless the FWISD and its representatives from any claims or cause of action directly or indirectly related to the
photographing, videotaping or audiotaping of my child for any lawful purpose; and
• to waive all monetary or other claims that might arise as a result of any lawful use of these materials.
I certify that I am the parent or legal guardian of the student mentioned below and that I am authorized to give permission and
consent.
______________________________
(Student’s name)
____________________________
(Name of school)
_______________________________
(Parent or Guardian’s Signature)
____________________________
(Date)
______________________________
(Address)
____________________________
(Telephone)
___________ I give permission for my child to be photographed, videotaped or audio taped.
___________ I DO NOT wish my child to be photographed, videotaped or audio taped.
FOR TEACHER OR SCHOOL OFFICE: Date Received
___________________
Revised: 04/29/11
B
Communications Department
100 N. University Dr., Ste. 258 Fort Worth, Texas 76107
OFFICE 817.814.1930 FAX 817.814.1935
www.fwisd.org
Estimado padre o guardián,
Por favor devuelva esta forma junto con el resto de la documentación a la escuela de su hijo(a) mañana. Esta nota de permiso
la mantendrá archivada el maestro o director de su hijo(a) para eventos especiales que incluirán cualquiera de lo siguiente:
1) Personal del FWISD y/o
2) Prensa noticiosa (televisión, diarios, radio, revistas)
En conjunto con los programas del Distrito Escolar Independiente de Fort Worth con cualquier propósito legal, entiendo que,
sin ninguna otra notificación para mí, al conceder permiso con mi firma en este documento estoy de acuerdo con lo siguiente:
• Las fotografías del FWISD pueden ser reproducidas, estar sujetas a derechos de autor, ser retransmitidas a través de la
televisión o las estaciones de cable, publicadas o usadas en materiales del distrito (incluyendo su sitio Web) para distribución a
los empleados escolares y al público en general.
• Considero al FWISD y a sus representantes libres de responsabilidad en cualquier caso de reclamo, o a causa de acciones
directa o indirectamente relacionadas con fotografiar, video grabar o audio grabar a mi hijo(a) con cualquier propósito legal, y
• Renuncio a todo reclamo monetario, o a otros reclamos que puedan originarse como resultado de cualquier uso legal de estos
materiales.
Certifico que soy el padre o guardián legal del estudiante mencionado abajo y estoy autorizado para dar permiso y
consentimiento.
______________________________
(Nombre de estudiante)
____________________________
(Nombre de escuela)
_______________________________
(Firma de padre o guardián)
____________________________
(Fecha)
______________________________
(Dirección)
____________________________
(Teléfono)
___________ Permito fotografiar, video grabar o audio grabar a mi hijo(a)
__________ NO permito fotografiar, video grabar o audio grabar a mi hijo(a)
FOR TEACHER OR SCHOOL OFFICE: Date Received
___________________
Revised: 04/29/11
C
Fort Worth Independent School District
Parent Permission, Release, and Indemnity Trips Form
I hereby certify that my son/daughter
(Name of Pupil)
has my permission to participate in the trip of the
(Class or Sponsoring Group)
on the _______ day of ______________, _____, to
(date)
(month)
(year)
(Location or Description of Activity)
To the best of my knowledge, he or she is physically fit to engage in such activity and is not
suffering from any disease or injury.
I agree and do hereby waive and release all claims against the FWISD and any teacher,
employee, or other person engaged in the activity in question and agree to hold them harmless
from any and all liability relating to my son or daughter for any personal injury or illness that
may be suffered or any loss of property that may occur to my son or daughter.
It is understood that no child will be allowed to participate in this activity until this form is
signed by his or her parent or guardian.
Signed at
, Texas, this
(city)
day of
(date)
(month)
(year)
(Signature of Parent or Guardian )
(Street Address)
(Zip Code)
(Telephone Number)
Form 829
9-1
11-12 SY Bulletin Number One
F-43
Revised: 01/24/2012
C
DISTRITO ESCOLAR INDEPENDIENTE DE FORT WORTH
FORMULARIO DE PERMISO DE LOS PADRES
E INDEMNIZACIÓN PARA VIAJES DE PASEO
Por medio de la presente certifico que mi hijo/a
(Nombre del estudiante)
tiene permiso para participar en el viaje de paseo de
(Clase o grupo encargado)
el _____ de ____________________del ______, a ____________________________________
(día)
(mes)
(año)
(Lugar o descripción de la actividad)
Hasta donde yo tengo conocimiento, él/ella está físicamente bien como para participar en dicha
actividad y no sufre de ninguna enfermedad o lesión.
Estoy de acuerdo en liberar y evitar todo y cualquier reclamo en contra del Distrito Escolar
Independiente de Fort Worth y en contra de cualquier maestro, empleado o cualquier otra
persona relacionada con la actividad en cuestión y estoy de acuerdo en declararlos inocentes de
cualquier y toda responsabilidad relacionada con cualquier daño personal o perjuicio que pueda
sufrir o cualquier pérdida de propiedad que le pueda ocurrir a mi hijo/a.
Queda entendido que a ningún niño se le permitirá participar en esta actividad a menos que esté
formulario esté llenado y firmado por su padre/madre o guardián legal.
Firmado en ,
(ciudad)
Texas, el ______ de______________________ _____.
(día)
(mes)
(año)
(Firma del padre o guardián)
__________________________
(codigo postal)
(Dirección)
(Número de teléfono)
Form 829
9-1
F-44
Revised: 01/24/2012
D
Fort Worth Independent School District
Parental Permission Form and Release from Claims
During the school year we will be taking some field trips. These trips may be walking trips in the
neighborhood or a bus trip within the city or to nearby communities. We are asking for you to
sign one (1) permission and release form for the year. You will be notified each time before a
trip is to be taken.
has my permission to accompany his/her teacher or
other supervisory personnel on field trips authorized by the Fort Worth Independent School
District (FWISD) during the 2012-2013 school year. I hereby waive and release all claims
against the FWISD and any teacher, employee, or any other person engaged in field trips during
the school year and agree to hold them harmless from any and all liability relating to my above
named son/daughter for any personal injury or illness that may be suffered or any loss of
property that may occur to my child.
Signed at Fort Worth, Texas, on this
day of
Signature of Parent/Guardian
, year
Telephone No
Address
Distrito Escolar Independiente de Fort Worth
Formulario de Permiso de Padres y Renuncia de Reclamo
Durante el año escolar tendremos algunas excursiones. Las excursiones podrán ser caminatas por
la vecindad, en autobús alrededor de la ciudad o a comunidades cercanas. Les pedimos que
firmen un formulario y de permiso y reclamo al año y se les informará cada vez que haya una
excursión.
tiene mi permiso para acompañar al maestro u otro supervisor a
excursiones autorizadas por el Distrito Escolar Independiente de Fort Worth (FWISD) durante el
año escular del 2012-2013. Renuncio a todo reclamo contra el FWISD y contra el maestro o
cualquier persona relacionada con las excursiones durante este año escolar y estoy de acuerdo en
librarles de cualquier responsabilidad con respecto a mi hijo ya mencionado por accidentes
personales o enfermedad que pueda sufrir o cualquier pérdida de propiedad que sostenga.
Firmado en Fort Worth, Texas, este
día de
del año
Firma del padre/guardián
Dirección
Teléfono
9-1
F-45
Revised: 01/24/2012
E
RELEASE TO BE SIGNED BY
BOTH PARENT(S)/GUARDIAN(S) AND BY STUDENT
We, the undersigned Parents or Guardians and Student, represent that the undersigned student
plans to go on a study trip abroad during the school year of 20___- 20___ for study, recreation,
and sightseeing; that such trip is under the supervision of district personnel; and that teacherchaperones of the cooperating school districts are accompanying the students who will go on the
trip.
We understand that there are certain hazards involved in travel and that there is always an ever
present danger that a child could suffer some injury or could lose or suffer damage to personal
property.
Therefore, we agree and do hereby waive and release all claims against the teacher-chaperones,
any employees and trustees of the FWISD, and agree to hold each of them harmless from any
and all liability relating to the undersigned student for any personal injury suffered or any loss of,
or damage to, property that may occur. This release extends to any and all activities that may be
under the sponsorship of the teacher-chaperones/district personnel and, in addition thereto, to any
and all excursions, trips, or any other type of trip or activity in which the student may be
involved while participating in the study trip abroad during the school year 20__- 20__.
We are grateful for the interest evidenced by the chaperones, and we know that the child will be
cared for to the extent of their ability. However, this is a general and complete release and hold
harmless agreement in favor of said teacher-chaperones, any employee, and trustee of the Fort
Worth Independent School District while the children are on this trip.
We know and understand our legal rights and enter into this release knowingly and willingly.
Executed at____________________, Texas, this _____day of ______________
(city)
(date)
(month)
, ______
(year)
Parent or Guardian
Parent or Guardian
Student
Witnesses:
Both parents must sign.
9-1
F-55
Revised: 01/24/2012
E
DISTRlTO ESCOLAR INDEPENDIENTE DE FORT WORTH
ESTA DECLARACIÓN DEBERÁ SER FIRMADA POR AMBOS
PADRES/GUARDIANES Y POR EL ESTUDIANTE
Nosotros, los suscritos padres/guardianes y estudiante estamos de acuerdo en que el estudiante
mencionado esté inscrito para participar en un viaje de estudios fuera del país durante el año
escolar 20____ - 20____ ya sea en plan de estudio, recreación y visitas a lugares de interés; que
este viaje está bajo la supervisión del personal del distrito; y que maestros/chaperones de los
distritos escolares involucrados acompañarán a los estudiantes que participen en el viaje.
Entendemos que existen ciertos riesgos involucrados en los viajes y que siempre existe el peligro
que un estudiante pueda sufrir una lesión, daño personal o cualquier pérdida de propiedad.
Sin embargo, estamos de acuerdo en renunciar a/y liberar de todas las reclamaciones en contra
del maestro-chaperones, cualquier empleado o miembro de la Junta Directiva del FWISD, y
estamos de acuerdo en declararlos libres de cualquier y toda responsabilidad relacionada con
cualquier daño personal o perjuicio que pueda sufrir o cualquier pérdida de propiedad que le
pueda ocurrir. Esta renuncia de derechos se extiende a todas y/o cualquier actividad que sea
patrocinada por el personal del distrito/maestros-chaperones y además, servirá para cualquier
excursión, paseo, o cualquier otro tipo de viaje o actividad en la cuál el estudiante esté
involucrado mientras participa en el viaje de estudios fuera del país durante el año escolar 20___
- 20___.
Agradecemos el interés de los chaperones y sabemos de antemano que el estudiante será cuidado
al máximo de sus habilidades. Sin embargo, esta es una renuncia de derechos y una autorización
general y completa para evitar cargos contra los maestros-chaperones, cualquier empleado y
miembros de la Junta Directiva del Distrito Escolar Independiente de Fort Worth mientras los
estudiantes participan en este viaje.
Sabemos y entendemos nuestros derechos legales y aceptamos este contrato sabiendo y
queriendo.
Firmadó en _____________________________, Texas, el día _____ de___________________
(ciudad)
(fecha)
(mes)
(año)
Padre o guardián
Padre o guardián
Estudiante
Testigos: __________________________________
_____________________________
Ambos padres deben firmar.
Todas las firmas deben tener dos testigos.
Todas las copias deben firmarse.
9-1
F-56
Revised: 01/24/2012
F
MEDICAL INFORMATION
ADDITION TO PARENT PERMISSION FORM
This form must be completed for all out-of-district and overnight trips because there are times
when a student’s illness or injury requires the immediate attention of nearby doctors and/or
hospital. The school district employee in charge of the students will attempt to contact a parent,
guardian, or family doctor; however, in extreme emergencies, this signed form will be needed as
authorization for treatment of the student. (Students who have special medical problems and
those who require a specialized medical procedure should be accompanied by a parent/guardian
if possible.) Students requiring medication must have a Physician’s Medication Request form
completed and a parental consent form signed by the parent. All medication must be in a
pharmacy labeled container and administered by designated school employee.
I hereby give my permission to do whatever is deemed necessary in case of the illness or injury
of my child,
, in the event that none of the persons listed below can be
contacted. I give my full permission for medical services to be rendered for my child by the
attending emergency physician or sub specialist.
Business Phone:
____________________________________ Home Phone:
Name of Parent or Guardian
Address
City
State
Zip
Name, Address, & Phone Number of Individual to Contact Other Than Parent or Guardian
Name & Address of Insurance Company
(Check one) Individual Policy ________________ Group Policy _________________________
If Group Policy, Name of Employer_________________________________________________
Policy No.______________ Group No._______________ Contract No.____________________
Name, Address, & Phone Number of Family Doctor
_______________________________________ Date:
Signature of Parent or Guardian
Form 829A
NOTE: This completed form must be in the possession of the teacher at all times
during the trip.
9-1
F-27
Revised: 01/24/2012
F
DISTRlTO ESCOLAR INDEPENDIENTE DE FORT WORTH
INFORMACIÓN MÉDICA
ADICIÓN AL FORMULARIO DE PERMISO DE LOS PADRES
Este formulario deberá completarse para todos los viajes fuera del distrito y viajes de un día para
otro porque hay ocasiones en que la enfermedad o lesión de un estudiante requieren la atención
inmediata de un médico y/o el hospital más cercano. El empleado del distrito que esté a cargo de
los estudiantes procurará comunicarse con los padres, guardián o medico de la familia; sin
embargo, en caso de emergencia extrema este formulario firmado será necesario como
autorización para el tratamiento del estudiante. (Los estudiantes que tienen problemas médicos
especiales y aquellos que requieran atención especializada deberán ser acompañados por su
padre, madre o guardián, si es posible.) Los estudiantes que requieren medicinas deberán tener
un formulario llenado por un médico aprobando la administración de las medicinas y uno de
consentimiento firmado por el padre/madre o guardián. Las medicinas deberán estar en envases
adecuados con etiquetas de la farmacia, y serán administradas por el empleado designado por la
escuela.
Por la presente doy mi permiso para que se haga lo que se considere necesario en caso de
enfermedad o lesión a mi hijo/a
, en el evento de que no puedan ponerse en
contacto con ninguna de las personas enumeradas abajo. Doy mi permiso completo para que se
presten servicios médicos en caso de emergencia.
____________________________
Nombre del padre o guardián
Teléfono del trabajo: __________________
Teléfono de la casa: ___________________
Dirección
Ciudad
Estado
Zona Postal
Nombre, dirección y número telefónico de otra persona, que no sea el padre o guardián, con
quien uno se pueda comunicar.
Nombre y dirección de su compañía de seguros de salud.
(Marque una) Póliza individual _______________ Póliza de grupo ________________
En la póliza de grupo, nombre del patrono____________________________________
No. de póliza _____________ No. de grupo _____
_____ No. de contrato___________
Nombre, dirección y teléfono del doctor de la familia
______________________________________________________Fecha:__________________
Firma del padre o guardián
Formulario 829A
NOTA: El maestro deberá mantener este formulario completo en todo
momento durante el viaje.
9-1
F-28
Revised: 01/24/2012
G
Office of Professional Standards
100 N. University Dr., Ste. NE 111, Fort Worth, Texas 76107
OFFICE 817.814.1888/1886
Fax Forms to 817-814.1889/1887
REQUEST OF BACKGROUND CHECK FOR VOLUNTEER
*Please provide all requested information and print clearly.
For District Personnel Use Only
From (FWISD Admin./Designee): ____________________________________________
Organization (Campus/Department): _________________________________________
____________________________________________________________________________
Last
Name
Middle
(Maiden
Name(s)__________
if Applicable
Phone:
________________ First
Fax: ___________________
Date
of Request:
For Applicant Use Only
___________________________________________________________________________
Last Name
First
Middle (Maiden Name(s) if Applicable
__________________________________________________________________________
Date of Birth
Gender
Ethnicity
State Driver License or ID Number
__________________________________________________________________________
Address
City/Zip
Contact Telephone Number
Applicants Signature: _____________________________________________________
Texas Ed. Code 22.085©
A person must provide to the school
District, a driver’s license or another
form of ID containing the person’s
photograph issued by an entity of the
United States government.
Copy photo ID here
For Office of Professional Standards Use Only
Date Criminal Record Check Conducted: __________________________
OPS Reviewer’s Signature: ______________________________________
Clear:
________________
Not Clear:
________________ (Applicant may call OPS for clarification or appeal)
Revised 5/20/2010
G
Office of Professional Standards
100 N. University Dr., Ste. NE 111, Fort Worth, Texas 76107
OFFICE 817.871.1888/1886
Fax Forms to 817-814-1889 or 1887
SOLICITUD PARA LA REVISIÓN DE ANTECEDENTES PENALES
PARA VOLUNTARIOS
*Favor de proveer toda la información y escribir claramente.
Para uso exclusivo del personal del Distrito
From (FWISD Admin. /Designee): ____________________________________________
Organization (Campus/Department): _________________________________________
____________________________________________________________________________
Last
Name
Middle
(Maiden
Name(s)__________
if Applicable
Phone:
________________ First
Fax: ___________________
Date
of Request:
Para uso exclusivo del solicitante
___________________________________________________________________________
Apellido
Nombre
Segundo nombre (apellido de soltera) si aplica
__________________________________________________________________________
Fecha de nacimiento
Sexo
Grupo étnico
Licencia de conducir del estado
o número de identificación
__________________________________________________________________________
Dirección
Código postal
Teléfono
Firma del solicitante: _____________________________________________________
Texas Ed. Code 22.085©
Una persona debe proveerle al distrito
escolar una licencia de conducir u otra
forma de identificación, con fotografía
de la persona, emitida por una entidad
del gobierno de los Estados Unidos.
Poner aquí copia de la
identificación con fotografía
Para uso exclusivo de la Oficina de Estándares Profesionales
Date Criminal Record Check Conducted: __________________________
OPS Reviewer’s Signature: ______________________________________
Clear:
________________
Not Clear:
________________ (Applicant may call OPS for clarification or appeal)
Revised 5/20/2010
H
DPS Computerized Criminal History (CCH) Verification
(AGENCY COPY)
I, _______________________________________, have been notified that a Computerized Criminal
APPLICANT or EMPLOYEE NAME (Please Print)
History (CCH) verification check will be performed by accessing the Texas Department of Public Safety
Secure Website and will be based on name and DOB identifiers I supply.
Because the name-based information is not an exact search and only fingerprint record searches
represent true identification to criminal history, the organization conducting the criminal history check for
background screening is not allowed to discuss any criminal history record information obtained using the
name and DOB method. Therefore, the agency may request that I have a fingerprint search performed to
clear any misidentification based on the result of the name and DOB search.
For the fingerprinting process I will be required to submit a full and complete set of my
fingerprints for analysis through the Texas Department of Public Safety AFIS (Automated Fingerprint
Identification System). I have been made aware that in order to complete this process I must make an
appointment with L1 Enrollment Services, submit a full and complete set of my fingerprints, request a
copy be sent to the agency listed below, and pay a fee of $24.95 to the fingerprinting services company,
L1 Enrollment Services.
Once this process is completed and the agency receives the data from DPS, the information on
my fingerprint criminal history record may be discussed with me.
(This copy must remain on file by your agency. Required for future DPS Audits)
__________________________________
___________________________________________
Signature of Applicant or Employee
___________________
____________________
Date
Signature of Applicant or employee
_____________________________________
Agency Name (Please print)
Please:
Check and Initial each Applicable Space
CCH Report Printed:
YES ____ NO ____
_______initial
Purpose of CCH: ____________________________
_____________________________________
Agency Representative Name (Please print)
_____________________________________
Signature of Agency Representative
Hire ______ Not Hired ______
_______initial
Date Printed: _______________
_______ initial
Destroyed Date: _____________
_______ Initial
Retain in your files
________________
Date
Rev. 02/2011
H
DPS Verificación computarizada de antecedentes criminales (CCH)
(Copia para la agencia)
Yo, _______________________________________, he sido notificado que la Verificación
NOMBRE DEL SOLICITANTE O EMPLEADO (en letra de molde)
Computarizada de Antecedentes Criminales (CCH) se realizará tomando acceso al sitio web del
Departamento de Seguridad Pública de Texas y se hará en base al nombre y fecha de nacimiento que yo
proporcione.
Debido a que la información basada en el nombre no es una búsqueda exacta, y solo la
investigación de los antecedentes con las huellas dactilares representa una identificación real de los
antecedentes penales, a la organización que lleva a cabo la verificación de antecedentes penales no le está
permitido discutir ninguna información obtenida usando el nombre y la fecha de nacimiento. Por lo tanto,
la agencia puede solicitar que yo me someta a una investigación de mis huellas dactilares para clarificar
cualquier error de identificación basado en los resultados de la investigación por medio del nombre y la
fecha de nacimiento.
Para la toma de huellas dactilares, se me solicitará que envíe una serie completa de mis huellas
dactilares para análisis a través del sistema AFIS del Departamento de Seguridad Pública de Texas
(Sistema Automatizado de Identificación de Huellas Dactilares.) Se me ha informado que para completar
este procedimiento, debo hacer una cita con los servicios de inscripción L1, enviar una serie llena y
completa de mis huellas dactilares, solicitar que una copia sea enviada a la agencia mencionada abajo y
pagar una tarifa de $24.95 a la compañía que ofrece los servicios de huellas dactilares, servicios de
inscripción L1.
Una vez que este proceso esté completo y la agencia reciba los datos del DPS, la información de
mis antecedentes criminales obtenida con mis huellas dactilares podrá ser discutida conmigo.
(Esta página debe permanecer en los archivos de su agencia. Requerido para auditorías
futuras del DPS)
___________________________________________
__________________________________
Signature of Applicant or Employee
Please:
Check and Initial each Applicable Space
___________________
____________________
CCH Report Printed:
Signature of Applicant or employee
YES ____ NO ____
Date
_____________________________________
Agency Name (Please print)
_____________________________________
Agency Representative Name (Please print)
____________________________________
Signature of Agency Representative
____________________
Date
_______initial
Purpose of CCH: ____________________________
Hire ______ Not Hired ______
_______initial
Date Printed: _______________
_______ initial
Destroyed Date: _____________
_______ Initial
Retain in your files
Rev. 02/2011
I
PARENT/STUDENT UIL MARCHING BAND
ACKNOWLEDGEMENT FORM
No student may be required to attend practice for marching band for more than eight
hours of rehearsal outside the academic school day per calendar week (Sunday through
Saturday). This provision applies to students in all components of the marching band.
On performance days (football games, competitions and other public performances)
bands may hold up to one additional hour of warm-up and practice beyond the scheduled
warm-up time at the performance site. Multiple performances on the same day do not
allow for additional practice and/or warm-up time.
Examples Of Activities Subject To The UIL Marching Band Eight Hour Rule.
•
•
•
•
•
•
•
•
Marching Band Rehearsal (Both Full Band And Components)
Any Marching Band Group Instructional Activity
Breaks
Announcements
Debriefing And Viewing Marching Band Videos
Playing Off Marching Band Music
Marching Band Sectionals (Both Director And Student Led)
Clinics For The Marching Band Or Any Of Its Components
The Following Activities Are Not Included In The Eight Hour Time Allotment:
•
•
•
•
NOTE:
Travel Time To And From Rehearsals And/Or Performances
Rehearsal Set-Up Time
Pep Rallies, Parades And Other Public Performances
Instruction And Practice For Music Activities Other Than Marching Band And
Its Components
An extensive Q&A for the Eight Hour Rule for Marching Band can be
found on the Music Page of the UIL Web Site at: www.uil.utexas.edu
“We have read and understand the Eight-Hour Rule for Marching Band as stated above
and agree to abide by these regulations.”
Parent Signature_____________________________________Date____________
Student Signature____________________________________Date_____________
This form is to be kept on file by the local school district.

preparticipation physical evaluation --medical history revised 1-11-06

Transcripción

Documentos relacionados