Auburngirlshockey.com
Auburn High School
Athletic Training
Consent to Treat & Emergency Care Information
Student Athlete’s Name: Grade: Sport(s):
1. The undersigned athlete or guardian consents to the rendering of medical and allied health care at Auburn High School which may include acute care, medical and rehabilitation treatment, and emergency care procedure if necessary.
2. The athlete or guardian acknowledges that no guarantees will be made as the result of evaluation or treatment.
3. The athlete or guardian understands:
A. Each athlete or guardian has the right to consent or refuse consent to any proposed procedure or therapeutic course.
B. In the event where a physician’s opinion and treatment is needed, the athlete cannot return to athletic participation until clearance is given by such health care professional.
C. In accordance with Massachusetts state law, in the event of a concussion, the athlete must seek outside medical diagnosis and clearance before returning to athletic participation.
D. Emergency medical treatment may be necessary as a result of athletic participation. In the event that a guardian or emergency contact cannot be reached, the signature below provides consent to advance with emergency care and assumes such expenses.
4. The athlete or guardian understands the below medical history is to provide the athlete with the upmost care during athletic participation and will only be seen by the athletic trainer. Providing the information below is optional yet encouraged.
Allergies:
Medical condition/concern that may affect athletic participation:
Emergency Contact: Phone:
I hereby accept and agree to abide by the above procedures and regulations of Auburn High School athletic training facility.
Athlete signature (if over 18): Date:
Parent/Guardian signature: Date:
With any questions/concerns please contact
Tim Harold
tharrold@auburn.k12.ma.us
508.832.7711 ext 1011
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