• MEDICAL CONSENT, TREATMENT AUTHORIZATION AND HEALTH INFORMATION DISCLOSURE AGREEMENT

    MEDICAL CONSENT, TREATMENT AUTHORIZATION AND HEALTH INFORMATION DISCLOSURE AGREEMENT

  • Preamble

    1. The Participant acknowledges and agrees to the terms outlined in this Agreement. When the Participant is a minor, the Participant’s parent/guardian acknowledges and agrees to the terms on behalf of the Participant (collectively hereinafter the “Participant”).

     

    2. This Agreement is the official document relating to OPDL Game Day Medical Consent, Treatment Authorization and Health Information Disclosure to Ontario Soccer and Return to Play Sports Centre Inc.

     

    Medical Consent and Treatment Authorization

    3. The Participant gives permission and consent:

    a) To the officials, coaches and designates of Ontario Soccer and Return to Play Sports Centre Inc. to make decisions concerning emergency medical care and treatment, and where necessary to authorize or provide such care and treatment and arrange ambulance transport.

    b) For the Participant to receive emergency medical treatment in the event of injury, accident, and/or illness.

    c) To the certified first aid providers, including but not limited to, licensed first responders, physicians, athletic therapists, chiropractors, nurses, physiotherapists, or other medical professional, whose services might be required, to provide medical care and treatment to the Participant.

     

    Consent to disclosure of Health Information

    4. The Participant gives permission and consent:

    a) To release all injury related data, treatment and prognosis to Ontario Soccer and Return to Play Sports Centre Inc.

    b) To disclose such health information only upon the written request of the Participant to the Participant’s OPDL Club Coach.

     

    Ontario Soccer and Return to Play Sports Inc. will only use redacted health information for publication to the scientific community or for year-end reporting. Any disclosure will not include the Participant’s personal identifiable information, and any disclosed data will be averaged. All personal and health Information will be stored securely and managed in accordance with applicable privacy legislation.

  • Date*
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  • Athlete Date of Birth*
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  • Treatment & Healthcare Informed Consent

    Treatment & Healthcare Informed Consent

    Contact Information and Authorization
  • Format: (000) 000-0000.
  • Acknowledgement

    By executing this Agreement, the Participant (and their parent/guardian in the case of a minor) indicates that they have the understanding and capacity to communicate health care directives for the Participant and are fully informed as to the contents of this document and understand the full import of this grant of powers. The Participant may withdraw this consent at any time by contacting Ontario Soccer’s Privacy officer.

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  • Date
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  • Date
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