ARIZONA INTERSCHOLASTIC ASSOCIATION7007 N. 18TH ST., PHOENIX, ARIZONA 85020-5552

PHONE: (602) 385-3810

The Preferred Urgent Care of the Arizona Interscholastic Association

2019-20 CONSENT TO TREAT FORM

Parental consent for minor athletes is generally required for sports medicine services, defined as services including,but not limited to, evaluation, diagnosis, first aid and emergency care, stabilization, treatment, rehabilitation andreferral of injuries and illnesses, along with decisions on return to play after injury or illness. Occasionally, thoseminor athletes require sports medicine services before, during and after their participation in sport-related activities,and under circumstances in which a parent or legal guardian is not immediately available to provide consentpertaining to the specific condition affecting the athlete. In such instances it may be imperative to the health andsafety of those athletes that sports medicine services necessary to prevent harm be provided immediately, and notbe withheld or delayed because of problems obtaining consent of a parent/guardian.

Accordingly, as a member of the Arizona Interscholastic Association (AIA), ___________________________________ (nameof school or district) requires as a pre-condition of participation in interscholastic activities, that a parent/guardianprovide written consent to the rendering of necessary sports medicine services to their minor athlete by a qualifiedmedical provider (QMP) employed or otherwise designated by the school/district/AIA, to the extent the QMP deemsnecessary to prevent harm to the student-athlete. It is understood that a QMP may be an athletic trainer, physician,physician assistant or nurse practitioner licensed by the state of Arizona (or the state in which the student-athleteis located at the time the injury/illness occurs), and who is acting in accordance with the scope of practice undertheir designated state license and any other requirement imposed by Arizona law. In emergency situations, the QMPmay also be a certified paramedic or emergency medical technician, but only for the purpose of providing emergencycare and transport as designated by state regulation and standing protocols, and not for the purpose of makingdecisions about return to play.

PLEASE PRINT LEGIBLY OR TYPE

“I, _____________________________________, the undersigned, am the parent/legal guardian of,

__________________________________, a minor and student-athlete at _____________________________________________

(name of school or district) who intends to participate in interscholastic sports and/or activities.

I understand that the school/district/AIA employs or designates QMP’s (as defined above) to provide sports medicineservices (as also defined above) to the school’s interscholastic athletes before, during or after sport-related activities,and that on certain occasions there are sport-related activities conducted away from the school/district facilitiesduring which other QMP’s are responsible for providing such sports medicine services. I hereby give consent to anysuch QMP to provide any such sports medicine services to the above-named minor. The QMP may make decisionson return to play in accordance with the defined scope of practice under the designated state license, except asotherwise limited by Arizona law. I also understand that documentation pertaining to any sports medicine servicesprovided to the above-named minor, may be maintained by the QMP. I hereby authorize the QMP who providessuch services to the above-named minor to disclose such information about the athlete’s injury/illness, assessment,condition, treatment, rehabilitation and return to play status to those who, in the professional judgment of the QMP,are required to have such information in order to assure optimum treatment for and recovery from the injury/illness,and to protect the health and safety of the minor. I understand such disclosures may be made to above-namedminor’s coaches, athletic director, school nurse, any classroom teacher required to provide academicaccommodation to assure the student-athlete’s recovery and safe return to activity, and any treating QMP.

If the parent believes that the minor is in need of further treatment or rehabilitation services for the injury/illness,the minor may be treated by the physician or provider of his/her choice. I understand, however, that all decisionsregarding same day return to activity following injury/illness shall be made by the QMP employed/designated by theschool/district/AIA.

Date: ______________________ Signature: ____________________________________________________________

FORM 15.7-D 03/04/2019 NextCare is the preferred partner of the AIA. It is not required you visit NextCare locations for your healthcare needs. 1

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