Parent & Athlete Concussion Agreement
Only type in the boxes. The original forms have been scanned for your viewing but you cannot type on them. When you are finished, scroll to the bottom and click submit. After you click submit, you will receive a confirmation page. Once you reach the confirmation page, go back to the ASCS Athletics Forms page and submit any other forms that you need to.
Digital Signature of Parent/Guardian *
Read the Concussion Agreement below and enter your name to digitally sign.
Your answer
Digital Signature of Student Athlete *
Read the Concussion Agreement below and enter your name to digitally sign.
Your answer
Parent Handout
Athlete Handout
Athlete's Name *
Last:
Your answer
First:
Your answer
2019/20 school year athlete's Grade: *
Check "Volleyball" if your child is participating in volleyball during the 2019/20 school year.
You can check the box if your child plans to play this sport during the current school year.
Check "Basketball" if your child is participating in basketball during the 2019/20 school year.
You can check the box if your child plans to play this sport during the current school year.
Check "Cheerleading" if your child is participating in cheerleading during the 2019/20 school year.
You can check the box if your child plans to play this sport during the current school year.
Check "Track" if your child is participating in track during the 2019/20 school year.
You can check the box if your child plans to play this sport during the current school year.
Check "Cross Country" if your child is participating in cross country during the 2019/20 school year.
You can check the box if your child plans to play this sport during the current school year.
Address: *
Your answer
City: *
Your answer
Zip: *
Your answer
County: *
Your answer
Phone: *
Your answer
EMail: *
Your answer
Age: *
Your answer
School: *
Your answer
Name of Current Team
Your answer
Have you ever had a concussion? *
Your answer
If yes, how many?
Your answer
Have you ever experienced concussion symptoms? *
Your answer
Did you report them?
Your answer
Emergency Contacts *
Name:
Your answer
Relationship:
Your answer
Phone Number:
Your answer
Submit
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