We are pleased to bring the Young Hearts for Life® (YH4L) Cardiac Screening Program to your college. YH4L will provide this free heart screening called an electrocardiogram (ECG) to identify college students at risk for sudden cardiac death and to increase the public's awareness of this issue.
Please be aware that repeat ECG testing is recommended every 2 years. To date over 180,000 students have been screened as a result of YH4L. More information about the screening can be found here.
A simple ECG, when used to screen young adults 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 less than 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 want to assure your confidentiality,
privacy and individual modesty will be respected throughout all aspects of the program.
Only female technicians will test the women and they will be screened in an area separate
from the men.
Current Testing Dates Listed Below:
I give permission to participate in the Young Hearts for Life® Cardiac
Screening in which I will receive an electrocardiogram. 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.
I understand that my participation in the Young Hearts for Life® Cardiac
Screening is intended to identify heart abnormalities which may affect my health
during physical activities. I assume all risks associated with my 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 me 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 college will make their best efforts to keep my 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
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 participation in the Young Hearts
for Life® Cardiac Screening.