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athlete SUBMISSION

Please fill out the form to the best of your ability. Information will be kept private unless deemed necessary to report to the governing body. 

Medical Waiver

I CONSENT TO THE MEDICAL EVALUATION AND/OR TREATMENT for injuries/illnesses provided by the on-site Medical Team Personnel and/or Hospital/Medical Facility Staff (in the event that I have to be transported to a medical facility and/or emergency room/hospital). I authorize treatment by the on-site Medical Staff and/or Medical Facility/Hospital Personnel in the event of injury or illness occurring while I am in attendance at the event. I understand medical treatment available at an event may include but is not limited to: general first aid care for injuries and wounds, evaluation for possible illness or disease, taping, stretching, modalities such as heat or ice, muscle stimulator/TENS/ultrasound, over-the-counter medication/prescription medication (Rx by physician’s order only), soft tissue massage, wound closure, splinting, chiropractic adjustment, acupuncture, being fitted for a sling or crutches, as well as basic and/or advance life support as deemed necessary by medical personnel.​

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All medical evaluations completed by the on-site Medical Team Personnel for injuries or illnesses at events are considered CONFIDENTIAL and property of the on-site Medical Team. Copies of medical injury forms completed by medical personnel at an event, camp or during team travel can by requested verbally either by the injured person, or parent/legal guardian of a minor who has been injured at the time of injury or requested in writing at a later date from the on-site Medical Team. All injury report forms from any event will be put in a confidential and secured injury database. No information about an individual’s injury or illness will be released by the on-site Medical Team without that athlete's written permission in accordance with HIPAA Privacy Guidelines. Full injury report will only be released to an insurance agency upon the written request of the injured person and/or parent/legal guardian of a minor who has been injured.

Reason for Treatment

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