Consent to Treat

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Consent to Treat - Minor

OSU Sports Medicine - Bo Jackson's Elite Sports

Guardian Name *

Child Name *

Child DOB *

YYYY

I, "Guardian Name Listed above" , give consent for the staff of The Ohio State University Wexner Medical Center’s Sports Medicine program to provide my child, "Child Name Listed above", medical treatment, first aid, emergency medical care and or rehabilitative treatment during the Bo Jackson’s Elite Sports workouts, injury checks, recovery workouts, or exercise activities hereafter identified as the “Event”. *

Yes

I understand that as a service to the sponsors and the participants of the Event, The Ohio State University Wexner Medical Center’s Sports Medicine Department has agreed to provide preventative medical treatment, first aid, emergency medical care and rehabilitative treatment. While the Sports Medicine program employs athletic health care providers such as physicians, nurse practitioners, nurses, physical therapists and athletic trainers who are qualified to evaluate, treat, and rehabilitate certain injuries that participants may incur while participating in the Event, the staff are not assuming the role of my child’s personal health care provider. I understand that I need to provide them with any and all of my personal health information that might impact the services they provide to my child. *

Yes

Permission is hereby granted to the Sports Medicine staff, when necessary or advisable for my child’s care and treatment, to hospitalize, schedule appointments, and communicate with other physicians, medical care providers, athletic trainers counselors and all Bo Jackson’s Elite Sports staff regarding my child’s medical history and or treatment. Permission is granted to discuss my child’s injuries with necessary third parties, including but not limited to, the Bo Jackson’s Elite Sports staff as relevant to my child’s participation in this Event. This authorization is valid for one year, unless revoked by my written notice, provided said notice is received prior to release of the above-designated information. Information released by this authorization may no longer be protected by federal privacy rules, such as HIPAA, and may be subject to re-disclosure. *

Yes

In consideration for the medical services provided to my child, I, acting for my child, myself, my executors, administrator and assigns, do hereby release and forever discharge The Ohio State University, its Board of Trustees, its respective entities, administrators, faculty members, employees, and agents, including OSU Physicians Inc. and its physicians, from any and all claims that I might have with regard to damages, demands, or any actions whatsoever, including those based on negligence, in any manner arising out my child’s participation in this Event. *

Yes

I have read this entire Agreement to Release and Indemnify the University. I fully understand it, and I agree to be legally bound by it. *

Yes

Emergency Contact: Name *

Emergency Contact: Relationship to Participant *

Emergency Contact: Best Contact Number *

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