In order for a student to be eligible for the Rhythm Of Our Youth Cardiac Screening, a parent or guardian must submit the required information and provide a legally valid signature, all of which can be completed using the form below.
By entering the necessary information, a parent/guardian is granting their child permission to participate in the Rhythm Of Our Youth Cardiac Screening in which their child will receive an electrocardiogram. An electrocardiogram (also known as EKG or ECG) is a non-invasive test that measures the electrical activity of the heart and can detect certain heart abnormalities leading to sudden cardiac death.
A child’s participation in the Rhythm Of Our Youth Cardiac Screening is intended to identify heart abnormalities which may affect their health during physical activities. Parents/guardians assume all risks, as identified in the parent information letter, that may be associated with a child’s participation in the Cardiac Screening. Having completed this waiver, parents/guardians hereby waive release and discharge from any and all liability for claims they may have for damages against Morris Hospital, Rhythm Of Our Youth Program, the participating high school, and any and all individuals associated with this screening, their heirs, representatives and successors, and assignees for any and all injuries suffered by a child in connection with this screening.
By electronically submitting this information, parents/guardians understand that the Rhythm Of Our Youth Program, Morris Hospital, and the school will make their best efforts to keep their child’s health information confidential pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and its related Rules and Regulations and other state laws. In the event a child’s ECG result indicates that further evaluation is needed, Morris Hospital’s Rhythm Of Our Youth Program may contact the parent/guardian for additional information and may provide a form to the school excusing their child from strenuous physical activity until further evaluation by their pediatrician or primary care physician is completed.
Therefore, by providing an eletronic signature, parents/guardians acknowledge that they have read this Permission Form and Waiver and understand the risks associated with their child’s participation in the Rhythm Of Our Youth Cardiac Screening.