Authorization for the Release of Medical Information

Program Registration Forms: Runner Sign Up Waiver and Release of Liability and Assumption of Risk Agreement Participant Guide Authorization for the Release of Medical Information

In order for a student to participate in the We Run Our Community’s Kids (WeROCK) marathon training program, he/she must have a current Physical Screening & Physician Authorization Form (the Form) on file in the WeROCK office. The Form must include approval from a licensed physician for the student to participate in the program and must indicate that the physician completed a physical examination of the student within the most recent 30 days. The deadline for submitting the Form to the WeROCK office is November 8, 2019. Students without the Form on file as of this date will not be allowed to continue with the program for the remainder of the 2019-2020 season.

In order for the Physical Screening & Physician Authorization Form to be acceptable, the Form must be completed, in its entirety, by the parent/guardian and by the licensed physician, and must include the date of the examination, the physician’s signature, and a stamp from the doctor’s office or clinic where the examination was completed.

WeROCK also strongly recommends that all participants have an EKG test completed prior to participation in the marathon training program. Completion of an EKG will be left to the decision of the parent/guardian of the participant, and to the participant’s licensed physician, with the physician advising the parent/guardian on the risks of participating in the program without an EKG being completed.

Authorization for the Release of Medical Information 2019-2020

  • Date Format: MM slash DD slash YYYY

  • I hereby authorize medical information about the above named student to be released to We Run Our Community’s Kids (WeROCK) and to be retained in their offices as part of their permanent records. I understand that this medical information is to be released to WeROCK for the purpose of determining that the student is physically fit and able to participate in the WeROCK marathon training program, and that WeROCK will keep the information confidential. I also authorize any licensed physicians affiliated with WeROCK to review the Form as part of the determination process.

    Specific information to be released to, and held by, We Run Our Community's Kids:

    • Pre-participation Physical Screening & Physician Authorization Form
    • Pre-participation Release of Medical Information Form with recommendation of EKG test
  • I have discussed the risks involved with participation in a marathon training program with a licensed physician and I understand the risks.
  • This authorization shall be effective immediately and shall be valid until September 1, 2020.
  • Parent/Guardian (or Participant if 18 years of age or older)
  • Date Format: MM slash DD slash YYYY
  • Note: Pursuant to the Family Educational Rights and Privacy Act of 1974, this information will be made available, upon request, to the parent or pupil age 18 or older. This information will be handled in accordance with HIPAA regulations.
  • This field is for validation purposes and should be left unchanged.