Maple Lake High School

Maple Lake High School

Student Activity Emergency Card

Student Name:______DOB:______Grade:______

Activity/Sport(list all)______Home Phone:______

Mother’s Name:______Phone :______
Father’s Name:______Phone: ______

Email:______2nd Email:______

Non-Parent to reach in case of emergency from 3:00-5:00 pm (if parents can’t be contacted)

Name:______Phone:______

List any health concerns:______

Diabetes?______Epilepsy?______Asthma?______Allergies? ______List:

Family Physician or Clinic: ______Phone:______

Insurance Company: ______Group#______Policy#______

HIPAA Privacy Rule Release

I hereby authorize the certified athletic trainer contracted by Maple Lake High School to release information regarding the student-athlete’s protected health information and related information regarding any injury or illness during the student-athlete’s training and participation in athletics at Maple Lake High School. This “protected health information” (PHI) provides information about this athlete’s past and present health. The purpose of this release form is to explain whom this information will be released to and to obtain written authorization from the parent(s)/legal guardian(s) for release of this information.

The athlete’s PHI will be shared with school officials such as the head coach, activities director, school nurse, and substitute certified athletic trainer to determine the athlete’s eligibility to participate. Access will be closely guarded and PHI will be shared only when it is deemed necessary.

I, the parent/legal guardian, understand that I may revoke this authorization/consent at any time by notifying in writing the school’s activities director. In the event that I revoke this authorization/consent, it will not have any effect on actions taken by the Maple Lake High School officials prior to the revocation. This authorization/consent expires one year from the date it is signed. I have read and understand the information above.

Parent(s)/Legal Guardian(s):

______Date:______

Consent to Treat

In the event that an athletic injury should occur to the above named student-athlete I give my permission for them to receive proper/necessary care from a certified athletic trainer or coach employed by or representing Maple Lake High School. Furthermore, in the event that a medical emergency should occur and I cannot be contacted I give my permission for a school representative (coach, athletic trainer) to arrange for ambulance service to the nearest medical facility. Permission is also granted to the attending physician to proceed with any medical or surgical treatment, x-ray examination and immunization. In the event of serious illness, the need for major surgery, or significant accidental injury, I understand that an attempt will be made by the attending physician to contact me in the most expeditious way possible. If said physician is not able to communicate with me, the treatment necessary for the best interest of the above-named student athlete may be given.

Parent(s)/Legal Guardian(s):

______Date:______