MIS 4178 - Okaloosa County School District

MIS 4178
REV 4/13
OKALOOSA COUNTY SCHOOL DISTRICT
RISK MANAGEMENT
HIGH SCHOOL INTERSCHOLASTIC ATHLETICS PARENTAL PERMISSION, RELEASE
EMERGENCY MEDICAL AUTHORIZATION AND AUTHORIZATION TO RELEASE INFORMATION
NOTICE TO THE MINOR CHILD'S NATURAL GUARDIAN
READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR
MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING
THAT, EVEN IF OKALOOSA COUNTY SCHOOL DISTRICT, ITS SCHOOL BOARD, ITS
EMPLOYEES, AGENTS OR ASSIGNS USES REASONABLE CARE IN PROVIDING THIS
ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED
BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS
INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY
SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD'S RIGHT AND YOUR RIGHT TO
RECOVER FROM OKALOOSA COUNTY SCHOOL DISTRICT, ITS SCHOOL BOARD, ITS
EMPLOYEES, AGENTS OR ASSIGNS IN A LAWSUIT FOR ANY PERSONAL INJURY,
INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM
THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO
REFUSE TO SIGN THIS FORM, AND OKALOOSA COUNTY SCHOOL DISTRICT, ITS
EMPLOYEES, AGENTS OR ASSIGNS HAS THE RIGHT TO REFUSE TO LET YOUR CHILD
PARTICIPATE IF YOU DO NOT SIGN THIS FORM.
No student will be allowed to practice or participate in any organized interscholastic athletic activity until this document is
signed, notarized and returned to the school Athletic Department
Student Name _______________________________________________ Grade ____________________________
Address ____________________________________________________ Home Phone ________________________
________________________________________________________Emergency Phone _____________________
PURPOSE: To provide the consent of parents and/or guardians for students to participate in interscholastic activities of the School
District and provide a hold harmless and release of liability, to authorize the provision of emergency medical treatment for that
student who may become ill or injured during such activities and authorizing the release of protected health information
.PLEASE COMPLETE ALL PARTS
PART I - PARENTAL/GUARDIAN PERMISSION, ACKNOWLEDGEMENT AND RELEASE
A. I, ____________________________________hereby grant permission for __________________________(the "Student Athlete") to
participate at ____________________________ School during the school year, and I know of, and acknowledge that my child/ward knows of,
the risks involved in interscholastic athletic participation, understand that serious injury, and even death, is possible in such participation and
choose to accept any and all responsibility for his/her safety and welfare while participating in athletics. With full understanding of the risks
involved, I release and hold harmless my child's/ward's school, and the Okaloosa County School District, its School Board, its officers,
employees, agents or assigns, of any and all responsibility and liability for any injury or claim resulting from such athletic participation and
agree to take no legal action against the Okaloosa County School District, its School Board, its officers, employees, agents or assigns, because
of any accident or mishap involving the athletic participation of my child/ward.
I understand the Florida High School Athletic Association requires all students participating in interscholastic athletics be covered by a medical
insurance policy providing a minimum of $25,000 limit for medical expenses. I hereby certify ______________________ is covered by
medical insurance providing at least $25,000 for medical expenses. The name of our medical insurance company is
___________________________ which will cover this child in the event of an injury. I assume full responsibility and liability for any and all
expenses connected with an injury and/or illness that is not paid by our insurance company or through Military benefits if this child is entitled
to military privileges. I further certify I will notify the principal of the school this child is attending if there is any change in this insurance
coverage, and I will purchase the Student and/or Football insurance offered at the school. (STUDENT AND/OR FOOTBALL INSURANCE MAY BE
PURCHASED AT YOUR SCHOOL)
B. I grant the released parties the right to photograph and/or videotape my child/ward and further to use said child's/ward's name, face, likeness,
voice and appearance in connection with exhibitions, publicity, advertising, promotional and commercial materials without reservation or
limitation. The released parties, however, are under no obligation to exercise said rights herein.
C. I also hereby grant permission for my child/ward to be transported by private automobile and/or School District authorized transportation
during the school year in which this release is effective to and from all interscholastic sports events.
PART III – EMERGENCY MEDICAL AUTHORIZATION
In the event reasonable attempts to contact me at __________________________________ (Phone numbers) have been unsuccessful, I give
my consent for (1) the administration of any treatment deemed necessary by_______________________________(Preferred physician) or
____________________________(Preferred dentist), or in the event the designated preferred practitioner is not available, by another physician
or dentist and (2) the transfer and admission of the child to __________________________(Preferred hospital) or any hospital reasonably
accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentist concurring
in the necessity for such surgery are obtained prior to the performance of such surgery. I hereby authorize any treating physicians, including
athletic trainers and team volunteer doctors, to provide information to school officials regarding my child’s medical condition or injuries. Facts
concerning the child’s medical history including allergies, medications being taken, and any physical impairments to which a physician should
be alerted: ________________________________________________________________________________
MEDICAL PROVIDERS MAY ACCEPT A PHOTOCOPY OF THIS SIGNED AUTHORIZATION AS IF IT WERE AN ORIGINAL FOR
ALL PURPOSES.
PART IV – AUTHORIZATION/CONSENT FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
I hereby authorize the athletic trainers, sports medicine staff and other health care personnel representing
___________________________________ to release information regarding the Student Athlete’s protected health information and related
information regarding any injury or illness during the Student Athlete’s training for and participation in interscholastic sports at
____________________________ School. This protected health information may concern the Student Athlete’s medical status, medical
conditions, injuries, prognosis, diagnosis, athlete’s participation status, and related personally identifiable health information. This protected
health information may be released to other health care providers, hospitals and/or medical clinics and laboratories, Student Athlete’s coaches,
medical insurance coordinators, the school’s Athletic Director and Principal, athletic and/or school administrators, chaplains and/or clergy
members, and officials of the Florida High School Athletic Association. I also authorize the Student Athlete’s coaches and other school staff to
release protected health information to the athletic trainers, sports medicine staff and other health care personnel as identified above and to
other health care professionals providing services to the Student Athlete. As the parent or guardian of the Student Athlete, I hereby confirm that
I have signed this authorization/consent for the disclosure of the Student Athlete’s protected health information voluntarily. I understand that
my child’s protected health information is protected by federal regulations under the Health Information Portability and Accountability Act
(HIPAA) of the Family Educational Rights and Privacy Act of 1974 (the Buckley Amendment) and may not be disclosed without either
parent/legal guardian authorization under HIPAA or consent under the Buckley Amendment I the parent/legal guardian understand that once
protected health information is disclosed per authorization or consent, the information is subject to re-disclosure and may no longer be
protected by HIPAA and/or the Buckley Amendment. I, the parent/legal guardian, understand that I may revoke this authorization/consent any
time by notifying in writing to the school’s Athletic Director, but if I do, it will not have any effect on the actions the
Okaloosa County School officials took in reliance on this authorization/consent prior to receiving the revocation. I understand that I may see
and obtain a copy of all protected health information described on this form, for a reasonable copy fee, if I ask for it. I further understand that I
may request a copy of this form after I sign it. This authorization/consent expires one year from the date it is signed.
I HAVE READ THE ABOVE AND AUTHORIZE THE DISCLOSURE AND RELEASE OF THE STUDENT ATHLETE’S
PROTECTED HEALTH INFORMATION AS STATED.
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Concussion & Heat Related Illnesses Information Release Form (EL3CH) must be signed along with this form, PRIOR TO
NOTARIZATION, and the terms and conditions of the EL3CH Form are considered incorporated into this Authorization.
BY SIGNING BELOW I VERIFY THAT I HAVE READ, REVIEWED AND COMPLETED ALL
THREE(3) PARTS OF THIS PERMISSION AND AUTHORIZATION FORM AND KNOW IT
CONTAINS A RELEASE.
__________________
_________________________________________
______________________________________
Date
Printed Name of Parent or Guardian
Signature of Parent or Guardian
STATE OF FLORIDA-COUNTY OF OKALOOSA
The foregoing instrument was acknowledged before me this _______________________ by_________________________________________
Date
Name of Person Acknowledged
Who is personally known to me or who has produced _______________________________________ as identification and who did/did not take an oath
Type of identification
Signature of Notary Taking Acknowledgment
Name of Notary (Typed, Printed or Stamped)
Notary Expiration: ____________________