Recreation Department Parent Concussion Agreement
Related to Concussion Law 2011- Wisconsin Act 172

As a parent and as an Athlete it is important to recognize the signs, symptoms, and behaviors of concussions. By signing this form, you are stating you understand the importance of recognizing and responding to the signs, symptoms, and behaviors of a concussion or head injury. This form must be completed for every sports season and every youth athletic organization the athlete is involved with.

I have read the Parent Concussion and Head Injury Information and undestand what a concusison 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.

Athlete's Name *
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