This form is to be used after a student/athlete is removed from and not returned to activity/competition after exhibiting concussion symptoms.  The student/athlete should not be returned to activity until written authorization is obtained from an appropriate health care professional and the parent/guardians.  This form should be kept on file at the school.

Download the form here.

This is the form that the South Dakota High School Activities Association recommends to those member schools that feel it is important to get consent from parents and/or legal guardians for medical treatment when away from home on road trips for various activities. This form should be kept on file at the school and another copy should travel with each team on which the athlete competes.

I, the Parent/Legal Guardian whose electronic signature appears below hereby consent my child who participates in co-curricular activities for High School to any medical services that may be required while said child is under the supervision of an employee of the School District while on a school-sponsored activity and hereby appoint said employee to act on behalf in securing necessary medical services from any duly licensed medical provider. 

 CONSENT FOR RELEASE OF MEDICAL INFORMATION FORM (HIPAA)

1. I authorize the use or disclosure of the above named individual’s health information including the Initial and Interim Pre-Participation History and Physical Exam information pertaining to a student’s ability to participate in South Dakota High School Activities Association sponsored activities.  Such disclosure may be made by any Health Care Provider generating or maintaining such information. 

2. The information identified above may be used by or disclosed to the school nurse, athletic 
trainer, coaches, medical providers and other school personnel involved in the care of this student.   

3. This information for which I am authorizing disclosure will be used for the purpose of  determining the student’s eligibility to participate in extracurricular activities, any  limitations on such participation and any treatment needs of the student. 

4. I understand that I have a right to revoke this authorization at any time.  I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the school administration.  I understand that the revocation will not apply to information that has already been released in response to this authorization.  I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.   

5. This authorization will expire on July 1, 2021. 

6. I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal privacy laws or regulations.
 
7. I understand authorizing the use or disclosure of the information identified above is voluntary.  However, a student’s eligibility to participate in extracurricular activities depends on such authorization.  I need not sign this form to ensure healthcare treatment.

 
As an athlete/activities participant of the Tri-Valley High School, I have been informed and agree to obey all guidelines outlined in the Athletic Packet and South Dakota High School Activities Association rules, including and not limited to, the specified rules listed below.

By signing my name below, I authorize and acknowledge that I have read and understood the items listed below:

I have read the Tri-Valley Academic & Training Rules Eligibility
I have read the SDHSAA Directory/Participation/Safety Consent

After submitting please make certain to complete Step Three: Physical Form submission if needed. Click here.