I, ____________________________________, consent to medical treatment for athletic related injuries/illnesses by Medical Personnel and / or Hospital Medical Staff. I authorize treatment by such personnel in the event of injury or illness.
This care includes but is not limited to: preventative taping and padding; first aid treatment of injuries and emergency care of injuries, which may include use of a backboard and cervical collar; suturing, splinting or casting of wounds/injuries on site or in medical treatment facility; chiropractic adjustments and care; acupuncture treatments; use of AED, injected medications, oxygen or IV to stabilize an athlete's condition on site or in route to a medical personnel to be in the best interest of the health and well-being of the athlete.
____________________________________________________ ______________________
(Athlete's Signature) (Date)
As a parent or legal guardian of ____________________, who is under the age of 18, I hereby authorize medical treatment in the event of an injury or illness as outlined above for ___________________ while he/she is participating in the 2008 US World Class Invitational event by a member of event medical staff/personnel and/or cruiseship medical staff and/or hospital medical staff.
_____ I Agree _____ I Agree, with the following exceptions to treatment______________________________________
_____ I Do Not Agree
____________________________________________________ ______________________
(Parent/Guardian Signature) (Date)
All medical evaluations completed by US World Class Invitational medical personnel for athletic injuries are considered confidential and will be filed under the direction of the USA Taekwondo medical coordinator. Copies of medical injury forms can be requested verbally from the USA Taekwondo medical coordinator by the injured athlete, or parent of a minor athlete at the time of injury or requested in writing following the competition. The original injury report will remain on file. No information about an individual athlete will be released without that athlete's permission per Federal Guidelines except where it is necessary to file insurance claims directly associated with the injury of illness. Information pertaining to injury data without using an athlete's name will be released to the medical director, the medical coordinator or their assistants for purposes of injury research or recommendations for safety rule changes only. An athlete's name and injury will only be released in cases pertaining to head injuries requiring the athlete to not compete for 30 days per USA Taekwondo and World Taekwondo Federation rules. This information will be released to the medical director, medical coordinator, referee chairperson, tournament committee chairman, national events director, executive director, and documented within the secured USA Taekwondo online registration program for purposes of enforcing the 30-day-out rule in compliance with USA TAEKWONDO and WTF rules.
I have read and understand the above information as it pertains to my medical records of injury or illness which may occur and be treated at USA Taekwondo Sanctioned events. I also understand that if these guidelines are not followed as stated above that USA Taekwondo could be found in violation of Federal Guidelines set forth by HIPAA.
_______________________________________ _______________________________ ______________________
(Athlete's Signature) (Parent/Guardian Signature) (Date)
I, ____________________________, consent to having my image photographed while injured or ill by USA Taekwondo staff photographer or USA Taekwondo medical staff for purposes of documentation of the injury and/or publicity for USA Taekwondo, USA Taekwondo sports medicine. This publicity may include bit is not limited to advertisement in print or on the websites of said organizations. I know I have the right to decline the photographing of my image at the time of injury if verbally requested by myself, my parent or my coach per Federal Guidelines set forth by HIPAA. Furthermore I know I can request that such images be removed from publication or public view if I decide to decline their use at a later date for any reason simply by making that request in writing directly to the USA Taekwondo National Office. I understand that such pictures may be taken without any expectations of compensation for said photographic images.
_______ I Agree _______ I Decline
__________________________________________________ __________________________
(Athlete's Signature)
(Date)
As a parent of legal guardian of ____________________________, who is under the age of 18, I hereby authorize the photographic images of__________________________to be allowed if injured of ill unless otherwise verbally requested at time of injury/illness that no such photographs be taken at that time. Furthermore I know I can request that such images be removed from publication or public view if I decide to decline their use at a later date simply by making that request in writing directly to the USA Taekwondo National Office.
______ I Agree _______ I Decline
______________________________________________ ______________________
(Parent/Guardian Signature) (Date)
