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OSR Physical Therapy

CONTACTS:

Shannon Carroll, DPT
OSR- Eden Prairie
952-873-7400
Shannon.carroll@osrpt.com    

Katie Dahl, DPT
OSR- Minnetonka
952-512-2400
Katelyn.dahl@osrpt.com

Please note:  If you are reading this form to decide whether your child should participate in Sportsmetrics™ Training at OSR Physical Therapy, the term “you” refers to your child.

INTRODUCTION
Before agreeing to participate in testing and training, it is important that you read and understand the following explanation.  Prior to your first visit you will be asked to read and sign this consent form if you wish to participate, and you must be under the care of a physician, or have had a physical examination by your primary care physician within the past year. In order to undergo the testing and to begin training, you must have full, pain-free range of knee motion, no ankle or knee instability and no joint swelling.   

First Sports Injury Testing—
The Sports Injury Test will be performed before Sportsmetrics™ Training begins and then again after completion of the training program.  The first Sports Injury Test will be performed to determine if you qualify to participate in training by evaluating your general medical history and by assessing your strength and flexibility, general coordination skills, and your jumping and landing technique.  These assessments will be made by using various physical exercise techniques which the testing personnel will discuss and demonstrate for you.

Sportsmetrics™ Training—
The Training Program will be conducted 2 per week for 6 weeks.  The training time will be approximately 60 minutes per day.    

The training program includes the following components:

The Dynamic Warm-Up will include various exercises to physically prepare your body for training.  This warm-up will prepare you for training by raising your body temperature, increasing blood flow to your muscles, and improving your flexibility, balance and coordination.

Plyometric Training focuses on correct jumping technique and is divided into three two-week phases.  Each two-week phase has a different training focus and the exercises change with each two-week phase.  The goal of jump training is to develop muscle control and strength for reducing the risk of knee injury and to increase jump height by performing various jumps and hops which will increase in complexity with each two-week phase.

Speed and Agility Training will emphasize body alignment and form while performing sprinting and cutting movements.  The goal of speed and agility training is to condition your body and increase skill level.

Strength Training will emphasize body alignment and form, while performing a structured strength-training program.  The goal of strength training is to improve your overall muscle efficiency.

Flexibility Training will require stretching through a complete range of motion to decrease injury and post-training soreness.

Second Sports Injury Test—
After completing the Sportsmetrics™ Training Program, a second Sports Injury Test will be performed.  The second Sports Injury Test will be conducted to determine the effect of the Training Program on your strength and flexibility, general coordination skills, and your jumping and landing techniques.  A detailed report of the results of the two Sports Injury Tests will be given to you.

RISKS, EXPERIENCE, BENEFITS AND PRECAUTIONS
The Sports Injury Test and Sportsmetrics™ Training Program may involve the following risks and/or discomforts:

Injury to the lower extremity
The training program is rigorous and includes double and single-leg jumping exercises and strength training activities.  Potential injuries include, but are not limited to, muscle strains and ligament sprains. These injuries are the same as those that can happen during any sports activities that involve jumping, running, pivoting, cutting and lifting.  The training program is done under the supervision of certified personnel who will conduct all of the training sessions.  If you experience any unusual pain, you should notify the certified personnel immediately.  You will receive a medical evaluation by an orthopedic surgeon as soon as possible if you sustain an injury during testing or training.

Generalized muscle pain
You may have generalized muscle soreness or stiffness as a result of the testing and training.  You should notify the certified personnel if you experience significant muscle pain or stiffness.

UNFORESEEN RISKS
There may be risks from participating in this training that are unknown.

BENEFITS
The benefits of the Sports Injury Test include an assessment of your knee and leg muscular strength, power, flexibility, coordination, and jumping/landing technique. This test may allow for the identification of any deficiencies that could place you at an increased risk for a knee injury.  There is no guarantee of benefit from participating in Sportsmetrics™ Training.

CONFIDENTIALITY
Records involving your participation in testing and training will be held confidential to the extent allowed by law and will not be released to the general public. Aggregate results may be published, but your name will not appear in any report or publication.

INJURY PROCEDURE
You may be injured as a result of your participation in the Sports Injury Test and Sportsmetrics™ Training.  OSR Physical Therapy staff will evaluate and immediately treat any unusual conditions that could occur during testing or training.

LIABILITY RELEASE:
By signing this document, you 1) expressly represent that you are in good health and are capable of full participation in rigorous physical activity; 2) agree to assume all risk of personal injury while attending and participating in this program; and 3) are acting for yourself, your heirs, personal representatives, and assigns, you release OSR Physical Therapy and any of its staff from any loss or liability whatsoever for any accident or injury, fatal or otherwise, which may result directly or indirectly from your involvement with this program.  4) Furthermore, I understand that by participating in the Sports Injury Testing and Sportsmetrics™ Training , it is not a guarantee that I will not sustain an injury during or after completion of the program. The Sports Injury Testing and Sportsmetrics™ Training is designed to decrease the likelihood of sustaining an injury, and does not eliminate the possibility of injury entirely.

FINANCIAL POLICY:
It is the policy that payment arrangements for participation be made at or prior to time of signing this document.  If during the course of this program you must terminate your participation due to injury or illness, you will receive a prorated refund for remaining sessions not attended upon receipt of written documentation from a licensed physician stating that you can no longer participate.  Missed sessions due to non-medical reasons cannot be made up and will not be refunded.

PHOTOGRAPH RELEASE:
Your photographs may be published or utilized by OSR Physical Therapy for educational, promotional or informational purposes.  Your photographs may also be used by other news media with the knowledge and permission of OSR Physical Therapy. Your identification will not be released with the photographs.

CONSENT
I have read and understand the preceding information.  I have had an opportunity to ask questions and all of my questions have been answered to my satisfaction.  This form is being signed voluntarily by me, indicating my agreement to participate in the Sports Injury Test or Sportsmetrics™ Training.  I do not give up any of my legal rights by signing this consent form.  I will receive a copy of this signed and dated consent form.

Today's Date: November 16, 2019

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
Have you done Sportsmetrics before?*
No
Yes

If yes, when?
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Have you done Sportsmetrics before?*
No
Yes

If yes, when?
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Have you done Sportsmetrics before?*
No
Yes

If yes, when?
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Have you done Sportsmetrics before?*
No
Yes

If yes, when?
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Have you done Sportsmetrics before?*
No
Yes

If yes, when?
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Have you done Sportsmetrics before?*
No
Yes

If yes, when?
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Have you done Sportsmetrics before?*
No
Yes

If yes, when?
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Have you done Sportsmetrics before?*
No
Yes

If yes, when?
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Have you done Sportsmetrics before?*
No
Yes

If yes, when?
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Have you done Sportsmetrics before?*
No
Yes

If yes, when?
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
By signing this consent form, I verify that I have the legal authority (legal custody) to give permission for this child to participate in the Sports Injury Test and Sportsmetrics™ Training with OSR Physical Therapy.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Have you done Sportsmetrics before?*
No
Yes

If yes, when?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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