CONCUSSION and SUDDEN CARDIAC ARREST ACKNOWLEDGEMENT AND SIGNATURE FORM FOR PARENTS AND STUDENT ATHLETES
Student Athlete’s Name *
Sport Participating In (Current and Potential) *
School *
Grade *
Student Electronic Signature (Type Name) *
As a student athlete, I have received and read both of the fact sheets regarding concussion and sudden cardiac arrest. I understand the nature and risk of concussion and head injury to student athletes,including the risks of continuing to play after concussion or head injury, and the symptoms of sudden cardiac arrest.
Parent Electronic Signature (Type Name) *
I, as the parent or legal guardian of the above named student, have received and read both of the fact sheets regarding concussion and sudden cardiac arrest. I understand the nature and risk of concussion and head injury to student athletes, including the risks of continuing to play after concussion or head injury, and the symptoms of sudden cardiac arrest.
Today's Date *
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Parent Email *
You will receive a copy of the completed form.
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