I, parent/guardian name*, am the parent and/or legal guardian of the minor student, student name*. I hereby authorize Chaminade-Madonna College Preparatory, its agents, employees, and associates, to release the protected student health records that is described below to JOE DIMAGGIO CHILDREN’S HOSPITAL (“JDCH”), 11005 Joe DiMaggio Drive, Hollywood, FL 33021, its agents, and employees. I understand that JDCH requires my child’s health records so that JDCH understands the basis of my child’s general health, potential health risks, limitation considerations, and/or need for additional clearance from a specialist before being cleared to return to a sport. I consent to allow JDCH team physicians to evaluate injuries obtained by my child while participating in Chaminade-Madonna College Preparatory activities or events.
The protected health information herein is specifically as follows:Any and all documentation from Chaminade-Madonna College Preparatory, generated in connection with JDHC/U18 including but not limited to: reports, charts, files, correspondence, notes, memoranda, radiology studies and films of any kind or nature, test findings, statements, treatment of any kind or nature, including psychological and psychiatric records, and any and all records regarding: student name *.
This protected health information is to be used in and during the 2025-2026 school year.This release may be revoked by a signed and properly dated written revocation. I understand that any such revocation does not apply to the extent that persons authorized to use or disclose my health information have already acted in reliance on this authorization. This authorization will expire after the 2025-2026 school year.