BUA ImPACT Consent and Release
Your child’s health and safety is paramount. Boston University Academy is proud to use ImPACT (Immediate Post Concussion Assessment and Cognitive Testing) to assist in evaluating and treating head injuries for all students who participate in Physical Education programming or after-school sports.

A computerized baseline exam will be administered at the start of the school year so that BUA’s consulting neuropsychologist can be a resource to your child’s physician to determine the appropriate course of action should an injury occur. A parent/guardian must provide consent or waive participation in ImPACT in order for the school to administer the ImPACT baseline exam. Additional information ImPACT is available at https://www.impacttest.com/audience/?parents-3.

* This consent form or waiver is required of all new BUA students as well as those returning students who intend to join an athletic team. New students are scheduled to sit for the ImPACT exam during Academy Transitions (August 28-30) and returning students in need of a retest will coordinate their testing with Mr. Stone, Director of Athletics. Families with multiple students enrolled at the school should complete this form for each individual student.

Student Name *
Your answer
Student Date of Birth *
MM
/
DD
/
YYYY
Name of Parent/Guardian Completing this Form *
Your answer
I would like for my child to participate in the ImPACT Concussion Management Program. *
Next
Never submit passwords through Google Forms.
This form was created inside of Boston University. Report Abuse - Terms of Service