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Medical Release Waiver

As a part of this registration process, I am providing medical information relating to my child(ren) to the city of West University Place and the West University Aquatic Club, Inc., d/b/a the West University Place Piranhas Swim Team and its employees, agents or representatives. I hereby authorize the city of West University Place and the West University Aquatic Club, Inc., d/b/a the West University Place Piranhas Swim Team and its employees, agents or representatives to disclose this protected medical information to any healthcare provider, Firefighter, Police officer, or other Emergency Medical Technician in order to obtain emergency healthcare for my child(ren). This authorization shall expire one year from the date of execution. I understand that, without exception, I have the right to revoke this authorization in writing. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal HIPAA privacy regulations. I do consent to the release of any information relating to psychiatric or psychological testing or treatment, biofeedback training, alcohol and/or drug abuse diagnosis, prognosis and treatment and/or HIV (AIDS) testing and/or results.

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