Dear Parents/Guardians,

We are pleased to bring the Young Hearts for Life® (YH4L) Cardiac Screening Program to your student's high school. All students whose parents authorize them to be tested will be screened. Please be aware that repeat ECG testing is recommended every two years.

YH4L provides free cardiac screenings which include an ECG (electrocardiogram) and may include a screening ECHO (echocardiogram) to identify high school students at risk for sudden cardiac death and to increase the public's awareness of this issue. To date over 100,000 students have been screened as a result of YH4L.

A simple ECG, when used to screen physically active young persons can detect certain serious heart conditions. Recording the electrical activity of the heart using electrodes attached to the skin with a mild adhesive, can detect approximately 60% of the abnormalities or “markers” from these heart conditions that are associated with sudden cardiac death that a stethoscope cannot. ECG screenings result in approximately 2% of the tests being falsely positive. This may require additional evaluation and testing by your physician. We believe that the benefit of this potentially life saving screening outweighs this concern.

We encourage you to discuss this screening with your child. Your child’s participation in the screening is your decision. We want to assure you that students’ confidentiality, privacy and individual modesty will be respected throughout all aspects of the program. Only female technicians will test girls and they will be screened in an area separate from boys.

Current Testing Dates Listed Below:
Lexington High School on 04/10/2015 - 04/10/2015

Benet Academy on 04/10/2015 - 04/10/2015

Maine East High School on 04/16/2015 - 04/17/2015

Waubonsie Valley High School on 04/23/2015 - 04/24/2015

Maine South High School on 04/30/2015 - 05/01/2015

I give permission for my child to participate in the Young Hearts for Life® Cardiac Screening in which my child will receive an electrocardiogram, and may receive an echocardiogram. 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. An echocardiogram is a non-invasive test that uses sound waves to create a moving picture of the heart that can detect heart abnormalities.

I understand that my child’s participation in the Young Hearts for Life® Cardiac Screening is intended to identify heart abnormalities which may affect their health during physical activities. I assume all risks associated with my child’s participation in the Cardiac Screening. All such risks being known and appreciated by me and having read this waiver I hereby for myself, heirs, executors, and administrators waive any and all claims I may have for damages against Young Hearts for Life and any and all individuals associated with this screening, their heirs, representatives and successors, and assignees for any and all injuries suffered by my child in connection with this screening or any actions or omissions related to the screening even though that liability may arise out of negligence or carelessness on the part of those named in this waiver.

I understand that Young Hearts for Life and your participating high school will make their best efforts to keep my 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 my child’s ECG result indicates that further evaluation is needed, Young Hearts for Life 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 acknowledge that I have read this Permission Form and Waiver and understand the risks associated with my child’s participation in the Young Hearts for Life® Cardiac Screening.