Parent/Student Concussion Form
Parents and student-athletes are asked to click on the links and read about concussions.
Parent name *
Your answer
By checking below I agree to this statement: 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. *
Required
Student Name *
Your answer
Have you ever had a concussion? *
If yes, how many?
Your answer
Estimated dates of concussions?
Your answer
Have you ever experience concussion symptoms? *
Your answer
Did you report them?
Your answer
By checking below I agree to this statement: 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. *
Required
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