department of athletics policies & procedures - UNC Wilmington ...

FORM B
AGENT OF RECORD STATEMENT
The University of North Carolina Wilmington
Department of Athletic Training
601 S. College Rd.
Wilmington, NC 28403
I, Dr. Walter Laughlin, MD State License #____________________________,
I, Dr. Bill Sutton, MD State License#_____________________________,
I, John O’Malley, MD State License#_____________________________,
Do hereby grant the following agency to the athletic training staff members listed below:
Scott Hill, MEd, ATC
Director of Athletic Training
Julie Francis, MEd, ATC Head Women’s Athletic Trainer
Aldo Plata, MS, ATC
Head Men’s Athletic Trainer
Stacy Downar, MS, ATC Assistant Athletic Trainer
Margery Ellis, ATC
Assistant Athletic Trainer
Stephanie Leimbach, MS, ATC Assistant Athletic Trainer
I authorize the above listed members of the University Of North Carolina Wilmington
Department Of Athletic Training to act as my agents as if they were in fact employees
under my supervision and guidance to assist me with the medical care and treatment of
UNCW student-athletes, coaches, and staff.
This agency is limited to my specific needs and may include among other things:
forwarding a prescription request on my behalf, contacting the pharmacy to on my behalf
to restock medications upon my instructions and protocols, signing as the recipient for
medication deliveries, storage, inventory control, record keeping, disposal, delivery,
transportation, of medical supplies and medications to and from my athletic medical
241