Scribd
Upload
0 views

Methodist Consent Copy

This document is a confirmation form for parents/guardians regarding their child's participation in a pre-participation physical exam event for student athletes at Rice Consolidated JH/HS. It outlines the limited scope of the exam, clarifies that it is not a comprehensive physical, and includes a release from liability for Houston Methodist. Parents are required to consent to the exam and the release of results to the school, acknowledging their understanding of the terms stated in the document.

Uploaded by

kchitmon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
0 views

Methodist Consent Copy

This document is a confirmation form for parents/guardians regarding their child's participation in a pre-participation physical exam event for student athletes at Rice Consolidated JH/HS. It outlines the limited scope of the exam, clarifies that it is not a comprehensive physical, and includes a release from liability for Houston Methodist. Parents are required to consent to the exam and the release of results to the school, acknowledging their understanding of the terms stated in the document.

Uploaded by

kchitmon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

Please Print in Box

Rice Consolidated JH/HS


School: _____________________________________

Student Name: _______________________________

Confirmation of Understanding of Limited Scope and Purpose of the


Extra-Curricular/Co-Curricular Pre-Participation Physical Exams

I, ________________________________, (Print Parent/Legal Guardian Name) am aware that my child/ward,


_____________________________ (Print Child’s Name), will attend an event providing pre-participation physical exams for
Rice HS
student athletes at ________________ May ____,
on ________, 8 20___25 (“the event”). The event is sponsored and provided by
Houston Methodist (“Houston Methodist”) for the sole purpose of clearing students for participation in extra-curricular/co-
curricular programs. The screening physical exam will be performed by volunteer healthcare providers. By signing this form, I
am confirming I understand and agree to the following:

• I consent to the extra-curricular/co-curricular physical exam for the above-named child.


• This is NOT a comprehensive physical exam and should not take the place of routine medical care; I understand that
this is a screening physical for clearance for participation in extra-curricular/co-curricular activities ONLY;
• Any patient-physician relationship created during the event will terminate immediately upon completion of the screening
physical;
• I understand that my child may need additional testing before he/she can be cleared for participation in athletic activities
and it is my sole responsibility to obtain such additional testing or medical care: I understand that if it is determined that
my child needs additional medical treatment; I will be notified of any such recommendation. I understand that a limited
number of non-invasive tests may be available and performed at the event for my convenience; I consent to any and
all additional non-invasive testing as deemed necessary by the screening physician during the event without
notification to me prior to the testing;
• I consent to the release of the results of my child’s physical screening exam to his or her school (including a coach,
athletic trainer, teacher or administrator) present at the event. This consent is valid for 180 days and I understand that I
may revoke this consent at any time. I understand that the information released may not be protected under the law
once it is disclosed and may be subject to re-disclosure by the Recipient.

___________________________________________________________________________________________________________
Parent/Guardian’s Signature Date

RELEASE FROM LIABILITY AND INDEMNIFICATION


I hereby release, waive, discharge and covenant not to sue Houston Methodist and its subsidiaries, officers, directors, trustees,
employees, agents and affiliated companies from any and all liability, claims, demands, actions and causes of action whatsoever
arising out of or related to any loss, damage, or injury, including death, that may be caused by or related to my child’s
participation or presence at the extra-curricular/co-curricular Physical Examination Event.
I acknowledge that I have read and understand the foregoing Release and that my signature below acknowledges the
statements made in the Release.

___________________________________________________________________________________________________________
Parent/Guardian’s Signature Date

Print Name: ___________________________________________________


Print Parent/Legal Guardian Name

STAY CONNECTED
Scan the QR code or visit houstonmethodist.org/subscribe to stay connected with
Houston Methodist on upcoming events, health tips and newsletters.

You might also like