Appendix 1 - Parent & Athlete Concussion Agreement
As a parent and as an athlete it is important to recognize the signs, symptoms, and behaviors of concussions. By signing this form you are stating that you read the attachments in the email sent along with this form and you are stating that you understand the importance of recognizing and responding to the signs, symptoms and behaviors of a concussion or head injury.
Email address
PARENT AGREEMENT: I, the parent of the athlete have read the parent information sheet on concussions. I understand what a concussion is and how it may be caused. I also understand the importance of reporting a suspected concussion to my child's coach and my child's teacher. I understand that my child must be removed from practice/competition if a concussion is suspected. I understand that I must provide written clearance from an appropriate health care professional to my teacher before my student returns to practice. I understand that there may be a possible consequence by returning to practice or competition too soon and that my student's brain needs to heal.
In the space provided my name represents my signature. Parents/Guardians, please type your first and last name below.
Your answer
Date Electronically Signed Parent Agreement: (ex. 3/9/16)
MM
/
DD
/
YYYY
STUDENT AGREEMENT: I, the athlete have read the student information sheet on concussions. I understand what a concussion is and how it may be caused. I also understand the importance of reporting a suspected concussion to my coach and my parents/guardians. I understand that I must be removed from practice/competition if a concussion is suspected. I understand that I must provide written clearance from an appropriate health care professional to my coach before returning to practice. I understand that there may be a possible consequence by returning to practice or competition too soon and that my brain needs to heal.
In the space provided my name represents my signature. Students, please type your first and last name below.
Your answer
Date Electronically Signed Student Agreement: (ex. 3/9/16)
MM
/
DD
/
YYYY
Homeroom Teacher:
Please complete the captcha before submitting the form.
Submit
Never submit passwords through Google Forms.
This form was created inside of School District of Janesville. Report Abuse - Terms of Service - Additional Terms