Homestead High School Free Heart Screening

Homestead HS Youth Heart Screening Registration Form
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Waiver Statement:

I, the undersigned, GIVE permission for my child (under 18 years old)/myself to voluntarily participate in the Kyle J. Taylor Foundation (The Foundation) cardiac screening (Cardiac Screening). A medical questionnaire will be reviewed, an electrocardiogram will be done, and an echocardiogram may be performed at the Cardiac Screening. The Cardiac Screening will be conducted by independent health care personnel and other volunteers working together with the Foundation. The undersigned acknowledges and agrees that participation in the Cardiac Screening is completely voluntary and that it is the undersigned’s decision to have my child/myself participate in this Cardiac Screening.

The information provided on the accompanying forms is, to the best of my knowledge, complete and correct. I understand and acknowledge that a finding of low risk from the limited screening being performed is not a guarantee of good health. Participation in this program cannot substitute for a consultation with a physician or other medical professional for any medical or health related condition or for regular physical examinations.

I understand and acknowledge that information received from this screening is to be considered preliminary only and does not constitute a diagnosis of my child’s/myself health or physical condition. This is not a diagnostic study and is not intended to replace regular check- ups with my child’s/my physician. I further understand and acknowledge that I or another parent/guardian should discuss any abnormal results with my child’s /my personal physician as soon as possible. I or another parent/guardian should ensure that any abnormal results from the Cardiac Screening are confirmed by a personal physician before any diagnosis or treatment is considered.

In order to have the Cardiac Screening performed on my child/myself and to participate in a screening, the undersigned, HEREBY RELEASES AND WAIVES ALL CLAIMS, ACTIONS, AND CAUSES OF ACTION that I or my child may otherwise have against the Kyle J. Taylor Foundation, the independent health care personnel and volunteers who are conducting or participating in this screening process, the school, the school district, and any vendors, sponsors, their officers, directors, employees, agents, volunteers, and representatives, from any claims, liability, or damages, including but not limited to personal injury or illness arising out of any physical, emotional, or mental injury or death that may occur in any way from my child/myself participation in this program resulting from the negligence, breach of warranty, or strict liability of any persons associated with the Cardiac Screening. The undersigned further agrees that neither the undersigned nor any of the undersigned’s heirs, personal or legal representatives of family members will bring suit or make a claim for illness, injury, or death resulting from the Cardiac Screening and that this release is binding upon my heirs, legatees, administrators, and personal representatives.

I understand that all of the medical information obtained through my child’s/my participation in this program will be kept confidential and will not be retained or used by the school or referring entity. Once the results of the Cardiac Screening have been disclosed to the participant, and/or the parent(s), all of the medical information obtained will be deidentified via the removal of personally identifiable information.

I certify that I have read this form or have had it read to me and that I fully understand this Consent and Release. In consideration of the ECG services provided by Kyle J. Taylor Foundation to Participant, I consent (i) to this Consent and Release and (ii) to Participant’s involvement in the ECG screening program.

By clicking the "Yes I agree" box,  you are confirming you are over 18 or the legal guardian of the student above and you accept the terms of the waiver.

 

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