Concussion and Injury Reporting Acknowledgment Form
IMPORTANT: This is a legal document. Please read and understand before signing.

Please click on the boxes below to indicate that you understand each of the following statements. Clicking on the boxes below in the equivalent to your initials: 

Sign in to Google to save your progress. Learn more
I understand that it is my responsibility to report all injuries and illnesses to my team coach and/or athletic trainer *
Required
After reading the CDC Concussion Facts Sheet for Athletes, I am aware of the following information: 
A concussion is a brain injury, which I am responsible for reporting to my team coaching staff and/or athletic trainer *
Required
A concussion can affect my ability to perform everyday activities, and affect reaction, time, balance, sleep, and classroom performance.  *
Required
You cannot see a concussion but you might notice some of the symptoms right away. Other symptoms might show up hours or days after the injury.  *
Required
If I suspect that a teammate has a concussion, I am responsible for reporting it with my coaching staff and/or athletic trainer. *
Required
I will not return to play at a game or practice if I have received a blow to the head or body that results in concussion-related symptoms.  *
Required
In rare cases, a repeat concussion in a young athlete can result in permanent damage to your brain. They can even be fatal. *
Required
Student Athlete's Electronic Signature  *
Date  *
MM
/
DD
/
YYYY
Student-Athlete Parent/Guardian Electronic Signature (Required if participant is under the age of 18)
Date 
MM
/
DD
/
YYYY
Sport *
Math CAPTCHA: 2 + 2 =
 *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of United International College. Report Abuse
Google Forms