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									                                           Medical Release and Waiver Forms

    Print Name of Student-Athlete                          Sports                                          Date

    Printed Name of Parent/Guardian (if under age of 18)            Relationship
I, the undersigned,
1. Certify to the best of my knowledge that my answers of this health history screening are complete and accurate.
2. Grant permission to Hood College athletic trainers, who are under the direction and guidance of Hood College consulting
     physician(s), to render any first-aid, rehabilitative, diagnostic, or emergency treatment that they deem reasonable and
     necessary to the health and well-being of the student–athlete.
3. When necessary for executing such cases, grants permission for hospitalization, scheduling of appointments and
     communication with physicians, physical therapist, counselors and other health care personnel regarding the student’s
     medical history.
4. Grant permission to Hood College consulting physician(s) to render said student-athlete any treatment, medical care or
     surgical care that they deem reasonably necessary to the health and well-being of the student-athlete.
5. Understand that if I am removed from a practice or a game or willingly leave a practice or game due to an injury or
     illness, I must provide appropriate written medical clearance by a healthcare provider before returning to play.
6. Understand that the parent or guardian of the student-athlete may not override the doctor’s decision for returning to play.
7. Understand that I may use my own physician and/or healthcare provider, however, the physician and/or healthcare
     provider, including second opinion purpose, MUST provide written documentation including the diagnosis of an injury
     or illness, playing status, and/or treatment protocol with their visits.
8. Understand that having passed a medical evaluation does not necessarily mean that I am physically qualified to engage in
     athletic, but only that the evaluator did not find a medical reason to disqualify me at the time of said evaluation.

    Signature of Student-Athlete              Date                  Signature of Parent/Guardian (if under age of 18)     Date

                     Responsibility of Reporting Injury and/or Illness, and Protective Equipment Use
I, the undersigned,
1. Have read and understand the NCAA Concussion Fact Sheet, and understand that I am responsible for reporting all
     injuries and/or illnesses to the sports medicine staff include signs and symptoms associated with concussion(s) and that I
     will not hide signs and symptoms of injuries and/or illnesses from the sports medicine staff and/or my coaches.
2. Read and understand all safety statements on all protective equipment in each participating sport. I understand that no
     helmet, faceguard, goggle, shoulder/chest pads, shin guards, and/or mouth guard can prevent head, face, neck, or other
     injuries a player might receive while participating in competitive sports. I understand that this equipment is not to be
     used to butt, ram, or spear an opposing player as it may result in severe head of neck injuries, paralysis, fracture, or death
     to me or my opponent. I also understand that there is a risk that injuries may occur as a result of accidental contact
     without the intent to butt, ram, or spear.
3. I agree to release, discharge, indemnify and hold harmless the Hood College, its officers, employees and agents from any
     and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that
     might result from my non-compliance with the mandate of the NCAA and Hood College Department of Athletics.
4. In consideration of Hood College permitting me to try out for an athletic team(s) and to engage in all activities related to
     the teams, including but not limited to trying out, training for, practicing or playing/participating, I agree to hold Hood
     College, its employees, agents, representatives, coaches and volunteers harmless from any and all liability, actions, cause
     of action, debts, claims or demands of any kind and nature whatsoever which may arise from or be connected with my
     participation in any activities related to the sport. Recognizing that true physical condition is dependent upon an
     accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or disabilities
     experienced, I herby affirm that I have fully disclosed in writing any prior medical history to the Hood College Sports
     Medicine personnel.
5. Have read signed this document with full knowledge of its significance.

    Signature of Student-Athlete              Date                  Signature of Parent/Guardian (if under age of 18)     Date
     Print Name of Student-Athlete                            Sports                                             Date

     Printed Name of Parent/Guardian (if under age of 18)               Relationship

                                                            Acknowledgement of risk
I, the undersigned,
1. Am aware of and accept the dangers and risks of athletic participation including but are not limited to: death, serious neck and spinal
      injuries that may result in complete or partial paralysis, brain damage; serious injury to virtually all bones, ligaments, muscles, tendons
      and other aspects of the muscular skeletal system and serious injury or impairment to other aspects of said student-athlete’s body,
      general health, and well-being.
2. Understand that athletic participation may result not only in serious injury, but in serious impairment of said student-athlete’s future
      abilities to have normal daily life living, to engage in other business, social, and recreational activities.
3. Comprehend the dangers of athletic participation and recognizes the importance of following the instructions of the athletics staff
      regarding play and performance techniques, training, and other rules, etc., and agrees to obey such instructions to reduce the risk of

     Signature of Student-Athlete                  Date                 Signature of Parent/Guardian (if under age of 18)             Date

                                           Disclosure of Protected Health Information
I, the Undersigned,
1. Authorizes Hood College sports medicine staff to discuss injuries and/or illnesses with necessary third parties, including but not
      limited to, the coaching staff and athletic director, as relevant to the student-athlete’s participation in practice, competition and/or
2. Understand that the Health Information Portability and Accountability Act (HIPAA) is a federal regulation that protects my health
      information. I understand that my signing of this authorization/consent is voluntary and that my institution will not condition any
      health care treatment or payment, enrollment in a health plan or receipt of any benefits (if applicable) on whether I provide consent or
      authorization requested for this disclosure. I also understand that I am not required to sign this authorization/consent in order to be
      eligible for participation in NCAA or conference athletics.
3. I herby request and give permission to Hood College Department of Athletics, sports medicine staff to release information obtained by
      Hood College (including health care providers working under an arrangement with Hood College) about me to my parents/guardians
      and health care providers working under an arrangement with Hood College for the purpose of their providing health care and
      treatment to me.
4. Understand that I may revoke this authorization at any time by sending a written notification to the Hood College Head Athletic
      Trainer. I understand that a revocation is not effective to the extent action has already been taken in reliance on this authorization.
      This authorization/consent will be signed each year the student-athlete participates in intercollegiate athletics.

     Signature of Student-Athlete                  Date                 Signature of Parent/Guardian (if under age of 18)             Date

                                                   Insurance Coverage Agreement
1.   It is the responsibility of each student to carry adequate health insurance privately or to purchase the health insurance offered by the
     college. By signing below, I acknowledge that I have read the information provided in the preparticipation packet and covered under
     a current insurance policy shown on a copy of a card. This insurance policy will cover injuries that occur during my participation in
     intercollegiate athletics, and this coverage has limits of at least $90,000. The NCAA has insurance coverage for catastrophic injuries
     that take over for an individual’s health insurance after $90,000 has been accrued. If there is ANY change in insurance coverage or
     expiration of coverage, I agree to notify Hood College Sports Medicine Center of the development and update the insurance
     information with a copy of new insurance card that I have on file with Hood College. I understand this and agree that Hood
     College will assume no responsibility whatsoever for the payment of, or authorization to pay, medical expenses resulting from injuries
     that occur while participating in intercollegiate athletics at Hood College.

     Signature of Student-Athlete                  Date

     Printed Name of Insurance Policy Holder                  Signature of Insurance Policy Holder               Date

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