Download Young Hearts for Life Packet

2222 West Church Street, Johnsburg, Illinois 60051
Dr. Dan Johnson, Superintendent of Schools, 815-385-6916
Kim Giovanni, Business Manager, 815.385.6916
Derek Straight, Curriculum Director, 815.344.5908
Richard Schisler, Director of Student Services, 815.385.6460
Dear Parents,
We are pleased to bring the Young Hearts for Life® (YH4L) Cardiac Screening Program to Johnsburg
School District on January 10, 2014. All students grades 7 through 12 whose parents authorize them
to be tested will be screened.
YH4L provides 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 90,000 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. Please note that
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.
We encourage you to complete the registration process on-line. If you do not have access to a
computer, please complete the attached registration form and have your student turn it into their PE
or Health teacher.
The Young Hearts for Life® Cardiac Screening is being provided free to Johnsburg School District
students by Advocate Good Shepherd Hospital in conjunction with community donations. If you
would like to donate to this worthy cause, please make checks payable to “Johnsburg School District
12” with “YH4L” written in the memo section. Upon receipt of your donation, a letter acknowledging
your contribution will be mailed to you for tax purposes.
For more information about this program, please visit their website at www.yh4l.org. If you have
any questions, please contact us at 815-385-6460.
Sincerely,
Fran Milewski
Student Services Assistant Director
YOUNG HEARTS FOR LIFE® (YH4L) CARDIAC SCREENING PERMISSION FORM & WAIVER
Please visit www.yh4l.org to register by January 8th, 2014
If you do not have e-mail access, please return this form to the school.
Student Name: _________________________________
Sex: ______
Height:______________
Student ID#: ________________ Date of Birth: __________
Weight: _____________
Grade: _________
Race/Ethnicity: Please circle all that apply.
American Indian/Alaska Native
Native Hawaiian/Pacific Islander
Black/African American
Asian
White
Hispanic
Sports: If your child participates in any of the following sport, please circle all that apply.
Baseball/Softball
Basketball
Biking
Cheerleading
Dance
Diving
Football
Golf
Gymnastics
Hockey
Lacrosse
Other:____________________
Marching Band
Martial Arts
Skiing
Soccer
Swimming
Tennis
Ultimate Frisbee
Volleyball
Weight Lifting
Wrestling
Track and Field
Home Address: Street: ______________________________________ Town: ________________________ Zip Code: ___________
Telephone: _________________________________ E-mail Address: ___________________________________________________
Pediatrician/Primary Care Physician Name: ________________________________ Telephone: ____________________________
I,
(please check one)
GIVE permission ☐
DO NOT give permission ☐
for my child,
_______________________________, to participate in the YH4L Cardiac Screening in which my child will receive
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 Advocate Medical Group, Johnsburg School District #12, 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 even though that liability may arise out of negligence or carelessness on the
part of those named in this waiver.
I understand that Advocate Medical Group and Johnsburg School District #12 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 of my child’s ECG result indicates that further evaluation is needed, Advocate
Medical Group 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. _____YES
_____NO
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.
_________________________________________ _________________________________ _______________________ _____
Name of Parent/Guardian (please print)
Parent/Guardian Signature
Relationship
Date
Charitable Donation Form
First Name _______________________________
Last Name _______________________________________
Company (if applicable) _______________________________________________________________________
In honor of (if applicable) ______________________________________________________________________
Address ___________________________________________________________________________________
City ________________________________________________
State _____
Zip _____________________
Donation Information
☐
$100+ Donation
Your sponsorship, at this level, will be acknowledged at our February board meeting and in the Spring
Info 12 community newsletter, and listed on our school website.
☐
$50 Donation
Your sponsorship, at this level, will be acknowledged in the Spring Info 12 community newsletter, and
listed on our school website.
☐
Individual Donation
Your sponsorship, at this level, will be listed on our school website.
Payment Information
Check # _______________________ Donation Amount ___________________________________________
(Payable to Johnsburg School District #12 with Young Hearts for Life® written in the memo section)
(All contributions are tax deductible to the extent allowed by law)
Signature: _________________________________________________________________________________
For further information, please call Student Services at 815.385.6460