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Dear Parent/Guardian:

As part of a contractual agreement between UPMC Sports Medicine and South Fayette School District, UPMC provides two certified athletic trainers to aide in the prevention, recognition, evaluation, and treatment of athletic injuries.

To treat your son or daughter, two forms must be signed by parents/guardians of student-athletes. One is the “Consent for Treatment, Payment and Health Care Operations.” This gives the athletic trainers and other associated healthcare personnel permission to assist or participate in providing care in the event of an injury or illness. The other form is the “Authorization for Release of Protected Health Information.” This form allows the athletic trainers to communicate with medical personnel and the school district’s athletic department personnel in order to provide consultation, treatment, and establish a plan of care for the injured or ill patient.

Please note that these forms have no relationship to your health insurance plan and in no way influence your choice of medical care. UPMC, as the employers of the athletic trainers at South Fayette School District, must have these forms completed in order to provide care for your son or daughter to comply with privacy and standard consent to treat laws.

In addition, copies of the UPMC Notice of Privacy Practices documents are available at the school, can be sent in the mail upon request, or viewed.

Please sign the consent documents. If you revoke this authorization or consent form, please contact the athletic office at
412-221-4542 x 240. We look forward to your student-athlete’s safe participation in South Fayette athletics. Thank you for your time.


Devin Kielur, LAT, ATC      
Certified Athletic Trainer                                       
UPMC Center for Sports Medicine                      
Larissa J Symington, LAT, ATC
Certified Athletic Trainer
UPMC Center for Sports Medicine

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