I, the parent or guardian of the above named athlete, a student athlete participating in interscholastic athletic sports, understand that the disclosure of the student-athlete’s protected health information is a condition of participation at O’Fallon Township High School-District 203
(“OTHS”).

I hereby authorize/consent for physicians covering OTHS 203 athletic events and Memorial Hospital’s Certified Athletic Trainer and other health-care personnel participating with the OTHS’s athletic program to release information regarding my student athlete’s protected health information (“PHI”) and related information regarding any injury or illness which may occur during the student athlete’s training for and participation in athletics at OTHS to any coach, athletic director or school official in connection with my student’s participation in interscholastic sports. This protected health information may concern the student-athlete’s medical status, medical condition, injuries, prognosis, diagnosis, athletic participation status and related personally identifiable health information. This protected information may be released to other health-care providers, hospital and/or medical clinics and laboratories, athletic coaches, athletic trainers, medical insurance coordinators, athletic and or school administrators, and officials of the student-athlete’s sport.

I understand that my student-athlete’s protected health information may be protected by federal regulations under the Health Information Portability and Accountability Act (HIPAA) and, if so, may not be disclosed without parent/legal guardian’s authorization.

I understand as parent or guardian of the student athlete:

• This authorization/consent is valid for the duration of the school year of the student athlete, unless Irescind my permission in writing to O’Fallon Township High School, District 203, 600 S Smiley St,O’Fallon, IL 62269.
• A revocation will not affect any uses or disclosures that the School, Southern Illinois Sports Medicine and Memorial Hospital’s Certified Athletic Trainer made before it received my student’s revocation.
• If I request it, I may see a copy of the PHI described on this form.
• The information that is used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA. I have the right to seek assurances from the above named entities or individuals authorized to receive the information that they will not re-disclose information to any other party without my further authorization.

I, the parent/guardian of the above named student, understand that my student-athlete may be injured while participating in school sponsored athletics. I hereby grant permission to physicians covering OTHS 203 athletic events and Memorial Hospital’s Certified Athletic Trainer to administer any preventative, first aid or emergency treatments to evaluate and examine, which they deem reasonably necessary to the health and well-being of my student-athlete.

I further understand and consent to the Certified Athletic Trainer’s providing advice to my student-athlete concerning nutrition, hydration and conditioning. The Certified Athletic Trainer may also provide to my student-athlete hot or cold packs, wound care, taping, massage, whirlpool treatment and therapeutic exercises which I also authorize and consent to be performed on my student-athlete during his/her participation in school sponsored athletics.

This consent form is valid for the duration of the student-athlete’s school year unless I rescind permission in writing to my student’s school district:

O’Fallon Township High School, District 203

600 S Smiley Street

O’Fallon, IL 62269

If I cannot be contacted and a reasonable effort has been made to do so, I authorize the coaching staff or the Principal and his or her designee to act on my behalf. I further authorize my son/daughter to be transferred and admitted to any hospital or medical facility for diagnosis and treatment if deemed necessary. I request and authorize any duly licensed Doctors of Medicine, Doctors of Dentistry or other such licensed technicians or nurses to perform any diagnostic, treatment or operative procedures including x-ray diagnosis of my child. I assume the responsibility for the payment of any such transfer and treatment.

Enter any known drug or food allergies. If none, enter N/A.

If parents cannot be contacted, please call:

Please click here to download your copy of the IHSA Performance-Enhancing Subsctance Testing Policy

Please click here to download the Concussion Information Sheet

By signing this form, we acknowledge we have been provided information regarding concussions and the IHSA Performance-Enhancing Testing Policy. We also acknowledge that we are providing consent to be tested in accordance with the procedures outlined in the IHSA Performance-Enhancing Testing Policy.