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Post-Concussion Consent Form
Completion of this form acknowledges consent to allow your son/daughter to resume participation in their respective sport.
PARENT/GUARDIAN NAME *
CROSS COUNTRY, BOYS
CROSS COUNTRY, GIRLS
SWIMMING AND DIVING, BOYS
SWIMMING AND DIVING, GIRLS
TRACK AND FIELD, BOYS
TRACK AND FIELD, GIRLS
WATER POLO, BOYS
WATER POLO, GIRLS
Your electronic approval below indicates that you acknowledge your son/daughter’s completion of the return to play protocol for a concussion and approve their return to competition and practices
I have been informed concerning and consent to my student’s participating in returning to play in accordance with the return-to-play and return-to-learn protocols established by Illinois State law;
I understand the risks associated with my student returning to play and returning to learn and will comply with any ongoing requirements in the return-to-play and return-to-learn protocols established by Illinois State law;
And I consent to the disclosure to appropriate persons, consistent with the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191), of the treating physician’s or athletic trainer’s written statement, and, if any, the return-to-play and return-to-learn recommendations of the treating physician or the athletic trainer, as the case may be
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