An ECG screen (also referred to as an EKG) can help identify young athletes who are at risk for sudden cardiac death, a condition where death results from an abrupt loss of heart function. An ECG screening may assist in diagnosing several different heart conditions that may contribute to sudden cardiac death.

By signing below, I am electing an ECG screen provided by Edgewater High School for my child. By electing to receive an ECG screen, I acknowledge the limitations of an ECG screen and that sudden cardiac death or other cardiac events may still occur, despite this screening. I further acknowledge that students with an abnormal ECG screen will be required to undergo further testing (e.g. an echo or ultrasound) and/or a medical consultation prior to being released to resume participation in Edgewater High School athletics. By my signature below, I hereby release and forever discharge, and waive, any and all claims against Edgewater High School for, its employees, sponsors, trustees, consultants, volunteers and contractors that relate to my election regarding and/or my child’s participation in this ECG screening project. I authorize medical personnel to review the ECG results, and interpret and use the same for diagnostic and aggregated statistical purposes in accordance with the Family Education Rights and Privacy Act and Health Insurance Portability and Accountability Act of 1996.

Note: Thanks to the generosity and hard work of Team Nina, Edgewater High School screenings are funded in the first year. Team Nina has provided a generous donation to assist families with the cost of this program if it will in any way be a financial hardship. Please choose one of the options below: *
Child's Name *
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Email *
Your answer
Never submit passwords through Google Forms.
This form was created inside of The Current Agency. Report Abuse - Terms of Service - Additional Terms