PARENTAL PERMISSION FOR RELEASE OF MEDICAL INFORMATION
To the Physician:
Your patient participates in a Fairfax County Public Schools (FCPS) athletic program and
thereby has contact with a certified athletic trainer (ATC). The FCPS Athletic Training
Program consists of athletic trainers certified by the National Athletic Trainers
Association (NATA) Board of Certification (BOC) and licensed by the Commonwealth
of Virginia’s Board of Medicine. ATC’s provide injury prevention programs, injury
evaluation, treatment, and rehabilitation services to FCPS student athletes.
Sound communication between and among all health care providers is key to providing
the best care to an injured athlete. This release is provided to encourage communication
between the treating medical physician and the athletic training staff at this athlete’s
school.
****** RELEASE ******
As parent or legal guardian of ______________________________, I grant permission
for the office of ______________________________ to release information pertinent to
the health care of my student athlete son/daughter to the athletic training staff at
____________________ High School.
I understand that the release of information may be in the form of personal
communication over the telephone, electronic form, letters or documents, reproductions
of originals of written material including X-Ray, MRI, or in person.
_________________________________
______________
Parent/Guardian Signature
Date
Any and all information shared will be considered confidential in nature, every effort
will be made to maintain confidentiality.