Wahpeton Huskies and BW Storm Athletics Health Forms, HIPAA

Please complete the form below for each athlete.

Athlete's Contact Information

First Name

Answer Required

Last Name

Answer Required

Birthdate

Answer Required

Grade

Answer Required

Sports Athlete is Participating In

Answer Required

Mother/Guardian Name

Answer Required

Phone Number

Number Required

Father/Guardian Name

Answer Required

Phone Number

Number Required

My athlete lives with:

Answer Required

Emergency Contact (other than parents/guardians)

Name

Answer Required

Mobile Phone

Number Required

Relationship

Answer Required

Health Information

Preferred Hospital

Answer Required

Physician Name

Answer Required

Does your child have or had: (please explain yes answers below)

Ongoing medical conditions

Answer Required

Asthma

Anemia

Diabetes

Other:

Surgery

Answer Required

Yes

Heart Conditions

Answer Required

Yes

An injury to a bone, ligament, or tendon that caused athlete to miss practices or games

Answer Required

Yes

Diagnosed Concussion

Answer Required

Yes

Allergies to food, insect stings, or medications

Answer Required

Yes

Please explain any yes answers from above, including dates.

Answer Required

Current Medications

Answer Required

Please list any other concerns you may have or other information you want the Athletic Trainer to know.

Answer Required

Huskies, Storm, Blades Athletics HIPAA Form

ND/MN AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION FORM (HIPAA)

Answer Required

I authorize the use or disclosure of the above-named individual's health and injury information including the Initial and Interim Pre-Participation History and Physical Exam information pertaining to a student's ability to participate in Minnesota State High School League/North Dakota High School Activities Association sponsored activities. Such disclosure may be made by any Health Care Provider generating or maintaining such information.

The information identified above may be used by or disclosed to the school nurse, athletic training provider, coaches, medical providers, and other school personnel involved in the care of this student.

This information for which I am authorizing disclosure will be used for the purpose of determining the student's eligibility to participate in extracurricular activities, any limitations on such participation and any treatment needs of the student relating to health conditions or injuries during the year that may affect participation.

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the school administration. I understand that the revocation will not apply to information that has already been released in response to this authorization.

I understand that once the above information is disclosed, it may be disclosed by the recipient and the information may not be protected by federal privacy laws or regulations.

I understand authorizing the use or disclosure of the information identified above is voluntary. However, a student's eligibility to participate in extracurricular activities depends on such authorization. I need not sign this form to ensure healthcare treatment.

This authorization will expire one year from the date of signature.

Signature of Parent*

Signature Required

Please fix the highlighted areas below before submitting.

Wahpeton Huskies and BW Storm Athletics Health Forms, HIPAA