Agreement to Participate in Heart Screening
Saving Hearts Foundation is offering a heart screening program for students, athletes, and young adults age 12-24. The information obtained from participants will be reviewed by medical personnel at the event. The identity of the screening participants and information obtained in the screening program will remain confidential and available only to Saving Hearts Foundation and the physicians helping at the event. The screening program may include:
- Medical History Questionnaire
- Blood pressure
- Physical examination
- Electrocardiogram (ECG- measures electrical activity in the heart)
- Echocardiogram (Echo- an ultrasound picture of the heart)
Data Collection, Analysis and Reporting
The data collected related to your heart screen will be reviewed by medical personnel participating in our event and may be used in an aggregate form (no names or identifiers) as part of a research study on heart screening in the young. In agreeing to your heart screen, you understand and provide permission that the information collected about you during the screening process, including the information contained in your medical Heart Health Survey, will be reviewed by medical personnel and can be included in a research study. Medical personnel will provide you with a summary of the results of your screening and may recommend additional evaluation through follow-up with your physician or specialist.
By agreeing to participate in the program, if so indicated you give permission to Saving Hearts Foundation and medical personnel to provide your screening results to your physician or cardiologist, and you authorize your physician to share the results and diagnosis of any subsequent testing with Saving Hearts Foundation.
I hereby give my permission for images of my child and/or myself, captured during a youth heart screening through video, photo or digital camera, to be used solely for the purposes of Saving Hearts Foundation's promotional material and publications and waive any rights of compensation or ownership thereto.
I acknowledge that I have read the above agreement to participate and understand its contents. Any questions have been answered to my satisfaction. I agree to be a participant in this heart screening, and in connection therewith, I consent to the release of information obtained in connection with the screening as described above. I understand that Saving Hearts Foundation will not disclose my identity to any third party without my consent. I understand that I may withdraw from the screening. I further agree to hold Saving Hearts Foundation, all physicians, technicians, volunteers, and all other persons, entities, individuals and organizations harmless and waive all subrogation rights against Saving Hearts Foundation and their directors, officers and volunteers as respects process and results of this free heart screening performed on this day.