Athletic Trainer Consent

Athletic Trainer

Parent/Guardian Consent Form

Student’s Name: _______________________________________________

I, as parent or guardian of the student identified above, hereby grant permission to any athletic trainer on site at any school sanctioned sports practice or competition at The Prout High School to provide such treatment within the scope of professional services authorized for such athletic trainer as deemed necessary for a physical condition arising during or affecting participation in such event. I also grant permission to release medical information to the school, to the athletic trainer and to any subsequent physician or other provider as necessary for treatment of the student identified herein. This authorization to release medical information does not encompass release of any information to the media or to any university or school except The Prout High School.  I acknowledge and agree that any such athletic trainer may use his or her own judgment in securing medical aid, including ambulance and other emergency services as a result of any injury during participation in a school sanctioned event. I specifically consent and agree that the above referenced athletic trainer may provide preventative care and treatment of athletic injuries and rehabilitation and reconditioning of athletic injuries.

By signing below, I agree and acknowledge that no athletic trainer (nor the athletic trainer’s employer Performance Physical Therapy) assumes responsibility and is not liable for any accident or injury that may occur during the student’s participation in an athletic event. I have been informed of the assumption of risk that accompanies participation of sports at The Prout High School.   I understand that the athletic trainer (and his or her employer Performance Physical Therapy) is not involved in the school athletic program other than providing the services noted herein.

Parent/Guardian Name: ________________________________________

Parent/Guardian Signature: _____________________________________

Date Signed: _________________________________________________

Contact Number: _____________________________________________