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 for "First Name"

Last Name

Answer required for "Last Name"

Birthdate

Answer required for "Birthdate"

Grade

Answer required for "Grade"

Sports Athlete is Participating In

Answer required for "Sports Athlete is Participating In"

Mother/Guardian Name

Answer required for "Mother/Guardian Name"

Phone Number

Number Required

Father/Guardian Name

Answer required for "Father/Guardian Name"

Phone Number

Number Required

My athlete lives with:

Answer required for "My athlete lives with:"

Emergency Contact (other than parents/guardians)

Name

Answer required for "Name"

Mobile Phone

Number Required

Relationship

Answer required for "Relationship"

Health Information

Preferred Hospital

Answer required for "Preferred Hospital"

Physician Name

Answer required for "Physician Name"

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

Ongoing medical conditions

Answer required for "Ongoing medical conditions"

Asthma

Anemia

Diabetes

Other:

Surgery

Answer required for "Surgery"

Yes

Heart Conditions

Answer required for "Heart Conditions"

Yes

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

Answer required for "An injury to a bone, ligament, or tendon that caused athlete to miss practices or games"

Yes

Diagnosed Concussion

Answer required for "Diagnosed Concussion"

Yes

Allergies to food, insect stings, or medications

Answer required for "Allergies to food, insect stings, or medications"

Yes

Please explain any yes answers from above, including dates.

Answer required for "Please explain any yes answers from above, including dates."

Current Medications

Answer required for "Current Medications"

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

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

Huskies, Storm, Blades Athletics HIPAA Form

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

Answer required for "ND/MN AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION FORM (HIPAA) "

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