Rangeland Rehab Permission Form: 2023 - 24
Dear Parents:

Rangeland Rehab P.C. in Ainsworth, NE currently provides sports medicine outreach services to your school thorughout the week, for the 2023 - 24 school year.  The Athletic Trainer and/or a Physical Therapist will be available to evaluate sports related injuries and to determine the course of treatment/rehabilitation of those injuries.  In order for your child to meet with the Athletic Trainer and/or Physical Therapist, it is necessary for you to sign the consent of treatment and information release form below.
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In the event of need, we/I hereby give our/my consent for my child to consult with the Athletic Trainer &/or Physical Therapist from Rangeland Rehab, and for the Athletic Trainer &/or Physical Therapist to share information only with the appropriate people (Coach, PE teacher, AD, ect.) regarding treatment of our/my child.
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Child Name: *
Parent/Guardian Electronic Signature: *
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