Concussion Agreement Form
Email address *
Please list other sports your child participates in
Your answer
Has your child ever had a concussion? *
Has your child ever experienced concussion symptoms? *
Please click on the link below to read the Athlete Concussion Fact Sheet
I have read the Athlete Concussion and Head Injury information and understand what a concussion is and how it may be caused. I understand the importance of reporting a suspected concussion to my coaches and my parents/guardian. I understand that I must be removed from practice/play if a concussion is suspected. I understand that I must provide written clearance from an appropriate health care provider to my coach before returning to practice/play. I understand the possible consequence of returning to practice/play too soon and that my brain needs time to heal.
Athlete Signature *
Your answer
Date *
Your answer
Please click on the link below to read the Parent Concussion Fact Sheet
I have read the Parent Concussion and Head Injury information and 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 providing written clearance from an appropriate health care provider to his/her coach. I understand the possible consequences of my child returning to practice/play too soon
Parent or Legal Guardian Signature *
Your answer
Date *
Your answer
A copy of your responses will be emailed to the address you provided.
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