Pa Medical Release Forms by gbe16204

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									                                         Mount Carmel Area School District
                                                              GREGORY A. SACAVAGE
                                                                ATHLETIC DIRECTOR
                                                                    600 W 5TH ST
                                                          MOUNT CARMEL PA 17851-1897
                                                     PHONE: 570-339-1500       FAX: 570-339-5567



                                              ATHLETIC RELEASE FORMS


           CONSENT FOR MEDICAL TREATMENT/RELEASE OF MEDICAL INFORMATION

I hereby agree to and give my consent for assessment and treatment that the school physician or his assistants deem necessary or
advisable in the event of an athletic injury during the 2008-2009 school year.

 Assessment and/or treatment may be performed at Mount Carmel Area High School facilities or at Dr. Jeffrey Greco’s office
located at 300 S. Hickory St., Mt. Carmel, PA. I understand that it is my responsibility to provide safe transportation to and
from these facilities for treatment.

I also authorize to disclose any medical information to the Family Physician, High School Principal, Athletic Director, School
Nurse, Coaches and other medical staff for a period of time not to exceed one year.

                 CONSENT FOR TREATMENT RELEASE OF MEDICAL INFORMATION

I hereby agree and give my consent for assessment and treatment that the athletic trainer or his/her assistants deem necessary or
advisable in the event of an athletic injury during the 2008-2009 school year.
Assessment and/or treatment may be performed at Mt. Carmel Area Junior-Senior High School facilities or at STAR Inc.,
Physical Therapy located at 600 Park Avenue, Marion Heights, PA. I understand that it is my responsibility to provide safe
transportation to and from these facilities for treatment.

I authorize to disclose any medical information to Team Physician, Family Physician, High School Principal, Athletic Director,
School Nurse, Coaches and other medical staff for a period of time not to exceed one year.


CONSENT FOR PUBLICATION OF STUDENT PHOTOS & VIDEO/INDIVIDUAL INFORMATION

I hereby agree to and give my consent for the use of my child’s photograph, video image and/or individual information such as
height, weight, and grade level for the 2008-2009 school year in publications such as the school yearbook, athletic programs,
school newspaper, local newspaper (the News Item) and school broadcast news.


The signatures below indicate that I (We) agree/disagree with and understand the information contained in the release forms.
                                       (Please circle one)


DATE:

SPORT(S):

STUDENT SIGNATURE :                                ___________________________________________

PARENT/GUARDIAN SIGNATURE:

RELATIONSHIP TO STUDENT:


                                        *Please return to your coach as soon as possible.*

								
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