08-09
Department of Athletic Training
Student-Athlete: ________________________________
(Please Print)
Please read the following consent forms carefully: Student-Athletes under 18 years of age must have a parent/guardian sign below If you choose to not sign any of these, please write refuse to sign along with the date and signature of student-athlete or parent/guardian. Please sign with blue or black ink.
I. MEDICAL CONSENT I hereby grant permission to the Averett University team physicians’ and/ or their consulting physicians to render myself or son/daughter to any treatment, medical, or surgical care that they deem reasonably necessary to the health and well being of the student-athlete. I also hereby authorize the athletic trainers at Averett University who are under the direction and guidance of the Averett University team physicians, to render son/daughter or myself any preventative, first-aid, rehabilitative or emergency treatment that they deem reasonably necessary to the health and well-being of the student-athlete. Also, when necessary for executing such case, I grant permission for hospitalization at an accredited hospital. _______________________________________ Student-Athlete Signature _______________________________________ Parent/Guardian Signature (if athlete is under 18) II. SHARED RESPONSIBILITY FOR SPORT SAFETY Participation in sports requires an acceptance of risk of injury. Athletes rightfully assume that those who are responsible for the conduct of sport have taken reasonable precaution to minimize such risk and that their peers participating in the sport will not intentionally inflict injury upon them. I have read the above shared responsibility statement. I understand that there are certain inherent risks involved in participating in intercollegiate athletics. I acknowledge the fact that these risks exist and I am willing to assume responsibility for such risks while participating in athletics at Averett University. ________________________________________ Student-Athlete Signature ________________________________________ Parent/Guardian Signature (if athlete is under 18) ______________________________ Date ______________________________ Date
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Revised 2/07
08-09
III. AUTHORIZATION FOR RELEASE OF INFORMATION This is to authorize the Averett University athletic trainers and team physicians to release all medical information on my son/daughter or myself to appropriate treating or consulting physicians, insurance companies, or Averett University administrators as deemed necessary by the athletic trainers or team physicians for medical treatment and/or insurance filing and medical expense payment. _______________________________________ Student-Athlete Signature _______________________________________ Parent/Guardian Signature (if athlete is under 18) ______________________________ Date
IV. AUTHORIZATION TO RELEASE INFORMATION I, __________________________________, hereby authorize and request Averett University, (Student-Athlete – please print) the Board of Trustees, the Averett University Athletic Department and their duly authorized agents, servants, or employees (including coaches, athletic trainers, and physicians) to furnish to all professional athletic teams, their scouts, representative agents, athletic trainers, physicians, servants or employees, any and all information concerning or having bearing upon my participation in intercollegiate athletics at Averett University. Said authorization shall include, but is not limited to, any and all information within their knowledge, or contained in any records under their supervision or control concerning my physical condition, illnesses, injuries and any treatment, hospitalization, examinations, x-rays, and otherwise, and to make such reports to such persons or organizations concerning myself as they may request; and I hereby fully discharge all parties to whom this authorization extends from any and all privilege in connection with the disclosure of information included in this authorization, including the privilege of nondisclosure of communications between physicians and patients. ________________________________________ Student-Athlete Signature ________________________________________ Parent/Guardian Signature (if athlete is under 18) _______________________________ Date
V. MEDICAL TREATMENT CONTRACT I agree to fully comply with the medical advice and instructions given to me by the Averett University Athletic Training Staff and Team Physicians. I understand that all decisions regarding my medical care and treatment are made in the best interest of my personal health and well-being, and that my failure to abide by those decisions could lead to further injury or illness. Additionally, I understand that should I choose to go Against Medical Advice (i.e. practicing when instructed not to, removing casts/splints prematurely, refusing appropriate treatment) I will be held financially responsible for any and all future physician referrals, surgeries, office procedures, treatments and diagnostic testing, including arrangement of and transportation to and from any related medical appointments. Averett University Athletic Training Staff will not coordinate any medical care that results from my decisions to ignore medical advice.
________________________________________ Student-Athlete Signature ________________________________________ Parent/Guardian Signature (if athlete is under 18)
________________________________ Date
2
Revised 2/07