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Required
Student Concussion Form
Athlete Information
First Name
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required
Last Name
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required
Grade as of 2022-23 School Year
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required
Please Select…
Grade 9
Grade 10
Grade 11
Grade 12
Student Email
Student Phone
What number should coaches use to communicate practice and game information?
Do you plan to play a Fall Sport?*
(i.e.: Cross Country, Golf, Soccer, Tennis or Volleyball)
Yes
No
I plan to play the following Fall Sport:*
Cross Country (girls)
Cross Country (boys)
Golf (girls)
Soccer (boys)
Soccer (girls)
Tennis (boys)
Volleyball
Do you plan to play a Winter Sport?*
(i.e.: Basketball, Cheerleading or Swim/Dive)
Yes
No
I plan to play the following Winter sport:*
Basketball (boys)
Basketball (girls)
Cheerleading
Swim/Dive (boys)
Swim/Dive (girls)
Do you plan to play a Spring Sport?*
(i.e.: Baseball, Golf, Softball, Tennis or Track)
Yes
No
I plan to play the following Spring sport:*
Baseball
Golf (boys)
Softball
Tennis (girls)
Track (boys)
Track (girls)
Student Concussion/SCA Acknowledgement
I am a student athlete, participating in the above mentioned sport. I have received and read the Student Athlete Information Fact Sheets for Concussion/Head Injury 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. I also understand the symptoms of Sudden Cardiac Arrest. Please type your electronic signature in the field provided below.
Yes, I agree with the above statement.
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required
Type your first and last name, to be used as your electronic signature.
Please send a confirmation email to the address below*: