Appearance Agreement: I further consent and grant to Rush Soccer (SPI) permission to use said child’s name, picture and likeness of but not limited to video, audio or internet rebroadcasts related to said child’s participation in Rush Soccer and its sponsored events for the purpose of highlighting individuals and teams for their achievements, awards and accomplishments. Parental or guardians permissions will not extend beyond aforementioned purposes without parents or guardians consent. Medical Info and Release (HIPPA): The Health Insurance Portability and Accountability Act has been in effect across the country for facilities that use health care providers as of April 14th 2003. There are three parts to this act. The first rule is the Transaction Rule, intended to standardize procedures, codes, and electronic billing format. The second rule is the Security Rule. This rule is designed to secure personally identifiable health care information being transmitted electronically. The third rule is the Privacy Rule. This rule creates national standards to protect individuals’ personal health information and gives patients increased access to their medical records. HIPAA affects Rush Soccer athletes via the various methods of documentation and communication that are used in the clinic/office as well as with coaches & physicians. The following signature will authorize the certified athletic trainer to communicate and view medical records pertaining to health related issues of the student-athlete. The following methods of communication and injury documentation will be used: Oral and written communication regarding health issues between the athletic trainer, coaching staff, and/or team representative and physicians. Oral and written communication regarding health issues between the athletic trainer and coaching staff. Oral and written communication regarding health issues between the athletic trainer and the athletes parents and/or team representative. Written documentation regarding injury evaluations and treatments (i.e. sign-in sheets and injury reports). Injury feedback forms to be submitted to the team representative when the athlete has seen a physician, physical therapist, or chiropractor for an injury (soccer-related or not). I have read and understand the means of communication and documentation that will take place regarding my health history and any injury information that may develop because of my involvement in Rush Soccer Sports Medicine Services. I authorize the release of medical information to the athletic trainer for the Rush Soccer club. I understand that I may be injured while participating in athletics with the Rush Soccer club. I also authorize the athletic trainer to administer treatments related to injury prevention and rehabilitation. Consent for Treatment: I understand that I may be injured while participating in athletics with the Rush Soccer Club. I authorize the coach, team representative, or athletic trainer to seek any emergency medical care that may become necessary while participating or traveling with Rush Soccer. I assume the financial responsibility for any medical treatment for my child. I also authorize the athletic trainer to administer treatments related to injury prevention and rehabilitation. Acceptance of Risk: I understand that participation in sports requires an acceptance of the risk of an injury. I understand that I may be permanently injured while playing sports and accept the risk. I understand I must follow all the rules of my sport. I understand that I must refrain from practice or play while injured or ill, whether or not receiving medical treatment and during medical treatment until I am discharged from treatment or given permission by a physician to return to participation despite continuing treatment. Acceptance to Festival: I understand that by submitting this form, I am not automatically accepted to the 2013 Rush Fest. Within a week of submission I acknowledge that I will receive an email follow-up either confirming my acceptance or denial, along with applicable fees owed, due dates, and necessary forms. Fees: I understand that upon my acceptance, I will receive an invoice of my final fees owed (including but not limited to: registration, hotel, ground transportation, Rapids Tickets, and t-shirts) along with payment schedule. I agree to adhere to this payment schedule and understand that past each due date, funds paid are non-refundable. |
