Medical Consent Form - Bloomsburg Huskies

BLOOMSBURG UNIVERSITY ATHLETIC TRAININGMedical Consent, Release, and Shared Responsibility InformationPLEASE PRINT YOUR NAME: __________________________________________________SS#: ____________________________ Sport: ____________________________________TERMINOLOGY:Medical Consent:To permit the Bloomsburg University Athletic Training Staff, team physician(s), and University HealthCenter medical staff to treat any injury that may occur during your active enrollment and athletic participation atBloomsburg University.Release of Information:To permit the release of any medical information or records to the Bloomsburg University Athletic TrainingStaff, team physician(s), or consulting physicians from the University Health Center, which may be forwarded on toyour coach or a professional scout concerning your health, welfare and your status for participation in your sport inthe immediate or distant future.Shared Responsibility for Sport Safety:Shows that you recognize that there are certain inherent risks that are possible when participating inintercollegiate athletics. As a Bloomsburg University athlete, you are willing to take responsibility for the potentialrisks that may occur while participating in Bloomsburg University Athletics.MEDICAL CONSENT:I give permission to the Bloomsburg University team physician(s) and/or consulting physicians as well as theBloomsburg University Athletic Training Staff to render any treatment that may be necessary to the health and wellbeingof my son, daughter, or myself. By authorizing the medical staff to render the necessary medical services, Iunderstand that this may include treatment such as medical or surgical care that may need to be provided by theattending team physician(s) or consulting physician.Also, by permitting necessary treatment for my son, daughter, myself, I realize that I am authorizing the BloomsburgUniversity Athletic Training Staff to render any treatment that may fall under the headings of preventive first-aid,rehabilitation, and emergency treatment. During these instances, the Certified Athletic Trainer will be working underthe supervision of the Bloomsburg University team physician(s) and/or consulting physician(s).I also realize that by giving my consent for the proper care of my son, daughter, or myself, I am giving consent forhospitalization when necessary at an accredited hospital._________________________________________________________Signature of Student-Athlete____________________Date_________________________________________________________Signature of Parent/Guardian (if student-athlete is a minor)____________________DatePAGE 1 OF 2

BLOOMSBURG UNIVERSITY ATHLETIC TRAININGMedical Consent, Release, and Shared Responsibility InformationAUTHORIZATION FOR RELEASE OF INFORMATIONIn signing the release of information form, I am authorizing the University Health Center to release medicalinformation on my son, daughter, or myself to the Bloomsburg Athletic Training Staff, team physician(s), orconsulting physician(s) concerning my health and welfare or status for participation in my sport. This medicalinformation may relate to the student-athlete’s past, present, and future injuries or illnesses that may occur or havealready occurred while participating in intercollegiate athletics at Bloomsburg University.Also, by giving the authorization for the release of medical information, I am permitting the Bloomsburg UniversityAthletic Training Staff, team physician(s), or consulting physician(s) to disclose information concerning my healthand welfare or status for participation in my sport in the immediate or distant future to coaches or professional scoutsif the need or opportunity arises. This information is normally confidential and will not be otherwise released. Thisrelease remains valid until revoked by the student-athlete in writing._________________________________________________________Signature of Student-Athlete____________________Date_________________________________________________________Signature of Parent/Guardian (if student-athlete is a minor)____________________DateSHARED RESPONSIBILITY FOR SPORTS SAFETYParticipation in sport requires an acceptance of risk or injury. Athletes rightfully assume that those who areresponsible for the conduct of sport have taken reasonable precaution to minimize such risk and that their peersparticipating in the sport will not intentionally inflict injury upon them.The NCAA and individual sport-governing bodies make periodic analysis of injury patterns, refinements in the rules,and other safety decisions. However, to legislate safety via a rule book and equipment standards, while oftennecessary, seldom is effective by itself, and to rely on officials to enforce compliance with the rule book isinsufficient as to rely on warning labels to produce compliance with safety guidelines. “Compliance” means respecton everyone’s part for the intent and purpose of a rule of guideline.I have read the above shared responsibility statement. I understand there are certain inherent risks involved inparticipating in intercollegiate athletics such as physical injury, permanent disability, paralysis or possibly death. Iacknowledge the responsibility for such risks while participating in Bloomsburg University Athletics._________________________________________________________Signature of Student-Athlete____________________Date_________________________________________________________Signature of Parent/Guardian (if student-athlete is a minor)____________________DatePAGE 2 OF 2