Canadian

Therapeutic

College

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SPORTS INJURY THERAPY:

FIELD PLACEMENT CONSENT TO THERAPY FORM

TO:   ________________________________ (the “Student”)

AND TO: Canadian Therapeutic College Corp.  (the “College”)

I am an athlete/team member/participant with the __________________ (the “Sports Body”).

I consent to the performance of sports therapy, sports injury therapy, massage therapy and related services (the “Therapy”) by the Student.  I fully understand that:

· The Student may not be a registered massage therapist and may not have professional qualifications to provide the Therapy to me,

· The Student is providing the Therapy to me as part of their educational training,

· The provision of the Therapy to me may not be supervised by a registered massage therapist or other health care professional.

The Student has explained the following to me:

· The nature, purpose and expected benefits of the Therapy,

· The material risks and any potential side effects of the Therapy,

· Alternate courses of action available to me,

· Any likely consequence to me of not receiving the Therapy

In particular, the Student has explained the following to me:

(include detail)

I have asked any questions I have concerning these matters and the Student has answered all of my questions. I am aware that I may terminate the Therapy at any time at my discretion without reason.  I agree to communicate all of my questions and concerns to the Student, especially any concern that my well being is being compromised.  I am aware that I may experience possible side effects from the Therapy, such as temporary discomfort within muscles (24-48 hours post-treatment), bruising and temporary dizziness. I understand that the College cannot and does not warrant the skills or knowledge of the Student or the quality of the Therapy provided by the Student to me.  I therefore release the College from any claims or demands that I or my heirs or legal representatives may have against the College relating to or arising from any injury, damages or costs I may suffer in connection with the Therapy provided by the Student.

DATED the ______________ day of __________ , 200__.

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witness                                                                         signature of athlete

(the athlete must be 16 years of age or older)

____________________________________________________________
witness                                                                         signature of parent or guardian

(I am the parent or person having lawful custody of the athlete named below and sign this consent on their behalf)

Name and address of athlete:

____________________________________________________________

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