Athlete Consent Medical Records Form
IMPORTANT: This is a legal document. Please read and understand before signing.

Authorization to Obtain Information

I authorize any physician, medical practitioner, hospital, clinic or medical facility, insurance or reinsuring company, the Medical Information Bureau, Inc., having information available as to diagnoses, treatment, and prognosis with respect to any physical treatment to me and to give to me and to United International College, Athletic's Department, Athletic's Training Staff, Insurance Comoany, or its legal representative, any and all such information. 

Any information obtained will not be released to any individuals or organization except to reinsuring companies, the Medical Information Bureau, Inc., or other persons or organizations performing business or legal services in connection with my application, claim or as may be otherwise lawfully required or as I may further authorize. 

Authorization for Release of Medical Records 

I hereby grant United International College Athletic Training Staff permission to release, if necessary, all information, and records, which relate to present and past medical history to the proper agencies (insurance companies, doctor outside United International College staff and professional teams). 

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Email *

I understand that as I submit this form, I will receive a copy of this authorization to my e-mail address. 

I agree that an electronic copy of this authorization is the original transcript. 

I understand that I may revoke the authorization at any time in writing to the Athletic Director. I also understand that any release which has been made prioe to my revocation and which was made based upon this authorization shall not constitute a breach of my right to confidentiality. 

I agree that unless revoked in writing, this authorization shall be valid as the original. 

I have read and understand the above stated policies 

Student-Athlete Electronic Signature: By entering your full name below, you are agreeing to use an electronic signature to acknowledge your understanding of this waiver. Your electronic signature is as legally binding as a handwritten signature.   *
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Student-Athlete Parent/Guardian Electronic Signature (Required if participant is under the age of 18)
Date  *
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Student Athlete's First Name  *
Student Athlete's Last Name  *
Sport *
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