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Baseline Testing Demographic Forms
Fill out the following form before completing the impact test:
Your School?
Choose
Brodgen
Dillard
Eastern Wayne Middle
Grantham
Greenwood
Mount Olive Middle
Rosewood Middle
Spring Creek Middle
Norwayne Middle
Wayne Christian School
Wayne Country Day
First Name:
Your answer
Last Name
Your answer
Date of Birth (Month/Day/Year)
MM
/
DD
/
YYYY
Current Grade in School
Choose
5th
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
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