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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 * *
Your answer
STUDENT NAME *
Your answer
SPORT *
STUDENT ID# *
Your answer
DATE *
MM
/
DD
/
YYYY
Parent Acknowledgement
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
Parent/Guardian Acknowledgement
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;
Parent/Guardian Acknowledgement *
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;
Required
Parent/Guardian Acknowledgement *
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
Required
Parent Email *
Your answer
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