KIWC - Concussion Waiver
Fully read the important information at the links provided. Sign-off via the questions below.
Parent/Guardian Signature *
Read the Concussion Packet: http://assets.ngin.com/attachments/document/0045/2056/Concussion_Packet.pdf. Parent Agreement: 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. This constitutes a legal signature of the Parent Agreement. Type your name.
Your answer
Parent/Guardian Signature Date *
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Athlete Signature *
Read the Concussion Packet: http://assets.ngin.com/attachments/document/0045/2056/Concussion_Packet.pdf. Athlete Agreement: 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. This constitutes a legal signature of the Athlete Agreement. Type your name.
Your answer
Athlete Signature Date *
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Athlete Name *
Questions and Contact Information Related to Concussion Law 2011 – Wisconsin Act 172. Type athlete name below.
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Date *
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Address *
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City *
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Zip Code *
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County *
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Phone Number *
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Email Address
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Age *
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School *
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School District *
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Check all that apply: *
This document must be completed at the beginning of every athletic season.
Required
Name of Current Team *
Your answer
1. Have you ever had a concussion? *
If yes, how many? *
Your answer
2. Have you ever experienced concussion symptoms? *
Did you report them? *
Emergency Contact 1 *
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Relationship *
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Emergency Contact 1 Phone Number *
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Emergency Contact 2 *
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Relationship *
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Emergency Contact 2 Phone Number *
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