PARENT AGREEMENT I have read the DPI’s Concussion and Head Injury Information sheet. I
have had the opportunity to read more information about concussions on the Centers for Disease Control and
Prevention’s (CDC) websites. I understand what a concussion is and how it may be caused. I also understand
the common signs, symptoms, and behaviors. I agree that my child must be removed from practice/play if a
concussion is suspected.
I understand that it is my responsibility to seek medical treatment if a suspected concussion is reported to me. I
understand that my child cannot return to practice/play until they are evaluated by an appropriate health care
provide and provide written clearance from the health care provider to their coach.
I understand concussions can have a serious effect on a young, developing brain and need to be addressed
correctly.
I have read the Sudden Cardiac Arrest information sheet. I understand that my child should stop
activity/exercise immediately if they have any warning signs of sudden cardiac arrest. I understand it is
recommended if my child has any warning signs of sudden cardiac arrest while exercising, they have a medical
examination before exercising or returning to participation in their sport. I understand that I or my child should
report a family history of heart problems or warning signs of sudden cardiac arrest to the healthcare provider
doing the medical examination.
I understand how to request at my cost the administration of an electrocardiogram, in addition to a
comprehensive physical examination required to participate in a youth athletic activity. I understand the
athletic director may be able to assist me. SIGN NAME BELOW *
