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Baseline Testing Demographic Forms
Fill out the following form before completing the impact test:
Your School?
Choose
Midway
Roseboro - Salemburg
Union
Hobbton
First Name:
Your answer
Last Name
Your answer
Date of Birth (Month/Day/Year)
MM
/
DD
/
YYYY
Current Grade in School
Choose
6th
7th
8th
Gender
Male
Female
Clear selection
Race
Asain
Hispanic or Latino
White
Black or African American
Native American or American Indian
Other:
Sports you play (or will play)
Cross Country
Football
Soccer
Volleyball
Golf
Tennis
Cheerleading
Basketball
Track and Field
Baseball
Softball
Wrestling
Other:
Have you ever had a concussion baseline test on the computer?
Yes
No
Clear selection
Have you ever been diagnosed with a concussion
Yes
No
Clear selection
Submit
Clear form
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