Please Read & Sign the Following Consent Forms Carefully

Medical Consent Forms Please print, complete, and return to: Kris Luellman – Athletic Trainer Mount Marty College 1105 W. 8th St. Yankton, SD 57078

PLEASE READ & SIGN THE FOLLOWING CONSENT FORMS CAREFULLY: .  PART I. Medical Consent: Allows MMC athletic trainers and physicians to treat any injury or illness incurred by you while at Mount Marty College.  PART II. Release of Information: Allows those listed to release and/or receive information concerning your injuries/illnesses to/from insurance carriers, medical personnel, and/or medical facilities.  PART III. Shared Responsibility: Provides information to you concerning certain inherent risks involved in participating in intercollegiate athletics and that you are willing to assume responsibility for such risks.

MEDICAL CONSENT – PART I AUTHORIZATION FOR I hereby grant permission to the Mount RELEASE OF INFORMATION – SHARED RESPONSIBILITY FOR Marty College (MMC) team physician PART II SPORTS SAFETY – PART III or other physicians designated by A. I hereby authorize Mount Marty The responsibility for sports safety must MMC to provide me with any medical College athletic trainers, school health be shared by all. Included in this group care or surgical care that they deem services, and team physicians to release should be administrators, coaches, reasonably necessary to my health and medical information to coaches, physicians, school health services, well-being as a result of injuries or insurance carriers, and one another any athletic trainers, and student-athletes. I, other medical conditions occurring as information concerning injury or illness the undersigned, am aware that there is a the result of or during MMC athletic relative to my past, present, future certain risk of injury involved in my activities. participation in athletics at Mount participation in Intercollegiate Athletics Marty College. at Mount Marty College. I understand I further authorize the athletic trainers that my signature does not relieve the as MMC who are under the direction B. I hereby authorize any medical College of it’s responsibilities to me. and guidance of the MMC team facility, physician, or medical This document is intended to make me physician to provide me with any personnel who has attended me to aware of my responsibility in preventing preventative, first aid, rehabilitative, or disclose when requested by MMC, any potential injuries, complying with the emergency treatment they deem and all information regarding my injury treatment plan of MMC athletic medical reasonably to my health and well-being or illness, medical history, consultation, staff, and that there is risk of injury. I as a result of injuries or other medical diagnostic tests, treatments, understand that this includes the risk of conditions occurring as the result of or recommendations, and all copies of spinal cord and brain injury that may during MMC athletic activities. hospital or medical records. result in paralysis and the possibility of other permanent injury or death. I have If reasonably necessary to provide the A photostatic copy of this authorization read the above shared responsibility care described in the preceding two shall be considered valid and effective statement. I acknowledge the fact that paragraphs, I grant MMC officials to as the original. these risks exist and I am willing to authorize hospitalization at a local assume responsibility for such risks hospital. while participating at Mount Marty College.

Athlete’s Signature Date Athlete’s Signature Date Athlete’s Signature Date I hereby grant permission on behalf of I hereby grant permission on behalf of my minor son/daughter/ward. my minor son/daughter/ward. I hereby grant permission on behalf of my minor son/daughter/ward.

Parent/Guardian Signature Date Parent/Guardian Signature Date Parent/Guardian Signature Date