Cardiac Screening Program Registration

I give permission for my child, or I (if I am registering myself and am 18 or older), to voluntarily participate in the In A Heartbeat Cardiac Screening, which will include an electrocardiogram (also known as an EKG or ECG). I understand that the Cardiac Screening will also consist of a medical questionnaire. An ECG is a non-invasive test that measures the electrical activity of the heart and can detect some heart abnormalities that may lead to sudden cardiac death.

The Cardiac Screening does not establish a treatment relationship between my child (or me, if I am the participant) and In A Heartbeat or the licensed healthcare providers administering the ECG. Participation in this screening cannot substitute for a consultation with a physician or other medical professionals for any medical or health related condition or for regular physical examinations. I understand that information received from this screening is to be considered preliminary only and does not constitute a diagnosis of my child's/my health or physical condition. This is not a diagnostic study and is not intended to replace regular check-ups with my child/my physician or to serve as a clearance for sports participation.

I understand that my child's participation, or my own participation, if I am registering myself, in the In A Heartbeat Cardiac Screening is intended to identify heart abnormalities which may affect health during physical activities. In order to have the cardiac screening performed on my child/myself and to participate in a screening I HEREBY RELEASE AND WAIVE ALL CLAIMS, ACTIONS, AND CAUSES OF ACTION that I or my child may otherwise have against In A Heartbeat, the health care personnel and volunteers who are conducting or participating in the screening process, the host of the cardiac screening, and any vendors, sponsors, their officers, directors, employees, agents, volunteers, and representatives, from any claims, liability, or damages including, but not limited to personal injury or illness arising out of any physical, emotional, or mental injury or death that may occur in any way from my child’s/my participation in the program resulting from negligence, breach of warranty, or strict liability of any persons associated with the Cardiac Screening. I further agree that neither I nor any of my heirs, personal, or legal representatives, or family members will bring suit or make a claim for illness, physical, emotional, or mental injury, or death resulting from the Cardiac Screening and that this release is binding upon my heirs, legatees, administers, and personal representatives. 

I understand that all of the medical information obtained through my child's/my participation in this program will be kept confidential. I understand that my child's/my results may possibly be used, after being de-identified via the removal of personally identifiable information, for research purposes in the future. I give consent that the remaining anonymized data can be collected by In A Heartbeat or its designees and that it may be used for medical and/or academic research purposes. In the event my child's/my ECG result indicates that further evaluation is needed, In A Heartbeat may contact me for additional information.

I grant permission to all the foregoing to use any photographs, recordings or any other record of this event for any legitimate purpose consistent with HIPAA and its related Rules and Regulations and other state laws. I also grant In A Heartbeat permission to email me with updates related to this screening and about the organization’s future endeavors. I understand that I can opt out from the emails at any time.