Heart Screening Consent and Release of Liability Waiver
1. About the Electrocardiogram ("ECG") Screening
An ECG screening (also commonly referred to as an EKG) is a test that measures the electrical activity of the heart to help identify an individual’s risk for heart conditions and some causes of sudden cardiac death. ECG screenings performed by Who We Play For (“WWPF”) involve (i) an ECG screening and (ii) a medical history form.
2. Consent to Participate and Acknowledgments
To receive an ECG screening, you must read and sign this Consent Form and Release of Liability (“Consent and Release”). If you are a minor, your parent or legal guardian must read and sign this Consent and Release. By signing below, you (or you and your parent or legal guardian if you are a minor) agree to the following:
---- I have carefully read this Consent and Release, I understand this Consent and Release, and I have had the opportunity to ask any questions; and
---- I voluntarily consent and elect to have representatives and volunteers perform an ECG screening; and
---- I understand that ECG screenings are noninvasive, painless tests and have no major risks. I voluntarily assume all risks associated with the ECG screening. I understand that the ECG screening will only screen for abnormalities in my heart and that it is not a complete medical exam or diagnosis. I understand that abnormal test results do not officially represent or imply that I have a heart condition. I understand that no warranty or guarantee has been made to me about the results of the screening. I understand that this screening will not diagnose all causes of sudden cardiac death. I acknowledge that the information I receive from the ECG screening reflects the condition of my heart at the time of the ECG screening. This ECG screening does not constitute a conclusive diagnosis of my heart health or physical condition; and is not intended to serve as a replacement for treatment and checkups with a primary care physician or other provider. I acknowledge the limitations of an ECG screening and that sudden cardiac death or other cardiac events may still occur, despite this screening. I understand that this ECG screening does not establish a treatment or provider relationship with anyone who administers the screening, interprets the ECG, or communicates the results. I recognize and acknowledge that I am solely responsible for taking any appropriate follow-up action related to the ECG screening results. I understand that follow-up care and treatment is not a part of this ECG screening program; and
---- I have the authority to sign this Consent and Release because either (i) I am an adult that is participating in the screening or (ii) I am the parent or legal guardian of a participant.
3. ECG Screening Results, Communication, and Confidentiality
The board-certified or board-eligible cardiologist that reads and interprets the ECG screening will place the participant into one of three categories: (i) low risk; (ii) follow-up required; or (iii) higher risk. You (or you and your parent or legal guardian if you are a minor) hereby acknowledge that if the ECG is categorized as “follow-up required” or “higher risk,” then you will be responsible for seeking follow-up care and additional testing (e.g., an echocardiogram) before further athletic activities. In certain counties and schools, you may be required to undergo additional testing prior to being allowed to resume participation with organized sports teams. You (or you and your parent or legal guardian if you are a minor) acknowledge, understand, and accept the following:
---- WWPF personnel, contractors, and volunteers (the “WWPF Team”) may disclose your screening results to individuals that oversee your involvement in athletics; and
---- The WWPF Team may contact me about the ECG screening and results. The participant’s screening results and medical history or health information may be used and disclosed by the WWPF Team for diagnostic purposes, follow-ups, aggregated statistical purposes, medical research, and research and development purposes. The information collected from any ECG screening event may be published in scientific journals or presented at scientific meetings in an aggregated way so long as you are not personally identified; and
---- The WWPF Team will follow all applicable state and federal laws and regulations, including any applicable sections of the Health Insurance Portability and Accountability Act (HIPAA) and the Family and Education Rights and Privacy Act (FERPA). This authorization may be revoked by submitting a written notice to WWPF at info@whoweplayfor.org
4. Waiver & Release of Claims and Liability
By signing this Consent and Release and in exchange for a no or low-cost screening, you (or you and your parent or legal guardian if you are a minor) hereby agree to waive any and all claims, liabilities, or damages against the following parties: (i) the WWPF Team or its employees, directors, officers, representatives, sponsors, trustees, partners, consultants, and its contractors including all interpreting cardiologists; (ii) if applicable, the School Board that oversees the school district in which the ECG screening took place, including the local School Board’s employees and agents; and (iii) if applicable, the school, university, college, or business in which the ECG screening took place, including their employees and agents (collectively, the “Indemnified Parties”). You (or you and your parent or legal guardian if you are a minor) further agree to indemnify, release, and hold harmless the Indemnified Parties from and against any and all claims, liabilities, damages, costs, and expenses arising out of or connected to the performance, interpretation, and/or communication of the results of this ECG screening.
5. Acknowledgment
You (or you and your parent or legal guardian if you are a minor) certify that you have read this form or have had it explained to you in a language you can understand and that you have been encouraged to ask any questions about the screening process, benefits, limitations, and risks.
Note: If you would like to “pay it forward” and donate to cover the cost for a student in financial need, please include the donation with your payment or reach out to WWPF at the screening event or at whoweplayfor.org – thank you!