Subject to Section 91.003, a health care practitioner who, without compensation or expectation of compensation, conducts a physical examination or medical screening of a patient for the purpose of determining the physical health and fitness of the patient to participate in a school-sponsored extracurricular or sporting activity is immune from civil liability for any act or omission resulting in the death of or injury to the patient if:
(1) the health care practitioner was acting in good faith and in the course and scope of the health care practitioner's duties;
(2) the health care practitioner commits the act or omission in the course of conducting the physical examination or medical screening of the patient;
(3) the services provided to the patient are within the scope of the license of the health care practitioner; and
(4) before the health care practitioner conducts the physical examination or medical screening, the patient or, if the patient is a minor or is otherwise legally incompetent, the patient's parent, managing conservator, legal guardian, or other person with legal responsibility for the care of the patient signs a written statement that acknowledges:
(A) that the health care practitioner is conducting a physical examination or medical screening that is not administered for or in expectation of compensation; and
(B) the limitations on the recovery of damages from the health care practitioner in connection with the physical examination or medical screening being performed.