SAMARITAN SPORTS MEDICINE PROGRAM PARENTAL/GUARDIAN CONSENT FORM Taft High School & Samaritan

SAMARITAN SPORTS MEDICINE PROGRAM PARENTAL/GUARDIAN CONSENT FORM Taft High School & Samaritan North Lincoln Hospital have entered into an agreement to provide sports medicine coverage for the Taft High School athletic program. The objectives of this program include: early injury evaluation to prevent further injury; provide appropriate care for an injured athlete; determine appropriate return to activity of an injured athlete; and to educate athletes, coaches, and parents regarding injury prevention and athletic performance enhancement. To achieve these objectives, the program has been set up to evaluate injured athletes at the school. A sports medicine member will be at the school two days a week to evaluate athletes at no cost to the athlete, the parents/guardian, or the school district. The coaches can send the injured athlete to the training room during predetermined dates/times for evaluation and treatment. Recommendations will be made regarding the athlete’s injury, athlete’s status regarding participation in their sport, appropriate treatment, and a plan for follow-up care if needed. An “Athlete Status Form” will be used to communicate evaluation findings, athlete status, treatment, and follow-up recommendations to the athlete, parent/guardian, and their coach. If a referral to a medical provider is recommended, those services may be subject to other fees as this service is not part of the sports medicine agreement. The athlete and their parents/guardian are free to choose any medical provider for the evaluation and we recommend that you follow your medical insurance guidelines regarding cost. Additional services provided outside of the athletic training room may incur a cost and examples of such services could include physical therapy, bracing, or medical tests. Samaritan Health Services will not bill for such services unless the athlete and their parents/guardian are first informed of such costs. The school district has mandated that all athletes evaluated and treated through athletic training room coverage must have a signed parental/guardian consent form signed prior to such evaluation and treatment. Signing this form will allow your athlete to be evaluated and treated at the high school training room by a SNLH sports medicine team member. Referral to the training room can be made by the parent/guardian or the athlete’s coach. There is no cost for this evaluation and/or treatment and parents/guardians maintain the right to make all medical decisions for their child. If you have any questions please feel free to call (541) 996-7160.

Athlete: ______DOB ____/____/_____ Sex: ____ Grade Level: ____

Parent/Guardian Signature: ______Date: ______

Print Name of Parent/Guardian: ______Phone: ______