Preparticipation Physical Evaluation: Medical History Form (Page 4 of 5) in pdf

This form authorizes the Maricopa Community Colleges and its colleges to release certain personal

information about you for educational purposes, including information that may be subject to the Family

Education Rights and Privacy Act of 1974 (FERPA) and the Health Insurance Portability and Accountability

Act of 1996 (HIPAA). Please read it carefully.

“Personal information” means specific information about you, including education records and personal health

information, that the Maricopa Community Colleges or its college(s) disclose: as a condition to permitting you to

participate in college intercollegiate athletics; to benefit you in pursing athletics beyond the Maricopa Community

Colleges; to address your health as you play college intercollegiate athletics; or to highlight the colleges’

intercollegiate athletics programs or your participation in them. It includes, as is appropriate to the specific use,

your name, address, telephone number, date and place of birth, medical or health conditions, major field of study,

participation in officially recognized activities and intercollegiate athletics, weight and height, dates of college

attendance, degrees and awards, grade point average, email address, intercollegiate athletics in which you have

participated and positions played, the name of your high school(s), the name of any other postsecondary institution

you have attended, and your home town. The term also includes any photo, portrait, video clip, or other image of

you created by any person for or on behalf the Maricopa Community Colleges, its colleges or any other educational

institutions that you have attended.

By signing this form, I certify that:

I have read and understand the definition of “personal information” specified in this form.

I authorize the release of personal information for the purposes specified in this form except that listed

here:_________________________________________________________________________________________

_____________________________________________________________________________________________

I authorize FULL DISCLOSURE of personal information concerning any athletic injury I may sustain

while participating in intercollegiate athletics at a college.

I understand that some or all of the following persons may be told about my health conditions: coaches,

media, parents, athletic directors, team physicians, doctors’ staff, referral sources, and the Maricopa Community

Colleges insurance brokers or companies.

I authorize the use and disclosure of personal information for the following purposes:



In promotional literature or video presentations about college athletic programs or about the Maricopa

Community Colleges in general;



In any Internet website maintained by or for the benefit of the Maricopa Community Colleges and its

colleges;



To disseminate to the National Junior College Athletic Association concerning my participation in

inter-collegiate athletics;



To include in any program or publication about an athletic event sponsored by the Maricopa

Community Colleges or its colleges or by any other organization and in which the Maricopa

Community Colleges or its colleges is participating;



To disseminate to other postsecondary institutions in connection with their recruitment activities;



To release to any newspaper, broadcasting entity, or any other media outlet;



To disseminate to any high school or other educational institution that I have attended.

I understand that I have the right not to consent to the release of my education records and to receive a copy of them

on request. This consent shall remain in effect until revoked by me, in writing, and delivered to the Maricopa

Community Colleges. Any revocation will not affect disclosures that the Maricopa Community Colleges made

before receiving my revocation.

___________________________________________

_______________________________________________

Signature of Student and Parent/Guardian if Student is

Print Name of Student

under 18

_______________________________________________

Date: ______________________________________

Print Name of Parent/Guardian if applicable

Preparticipation Physical Evaluation: Medical History Form Page 4

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