South Appleton Rocker Softball Association -  Parent & Athlete Agreement
As a Parent and as an Athlete it is important to recognize the signs, symptoms, and behaviors of concussions and sudden cardiac arrest. By completing this form (via electronic signature) you are stating that you understand the importance of recognizing and responding to the signs, symptoms, and behaviors of a concussion or head injury and sudden cardiac arrest.

Sign in to Google to save your progress. Learn more
Athlete Name:  *
Rockers Age Group *
PARENT AGREEMENT As a parent/guardian and as an athlete it is important to recognize the signs, symptoms, and behaviors of concussions and sudden cardiac arrest. By typing your name below, you are signing this form, you are stating that you have read the Department of Public Instruction’s (DPI) and the Wisconsin Interscholastic Athletic Association (WIAA) Concussion and Head Injury information sheet and Sudden Cardiac Arrest Information sheet. 

Parent Agreement:
I have read the DPI’s Concussion and Head Injury Information sheet. I have had the opportunity to read more information about concussions on the Centers for Disease Control and Prevention’s (CDC) websites. I understand what a concussion is and how it may be caused. I also understand the common signs, symptoms, and behaviors. I agree that my child must be removed from practice/play if a concussion is suspected. 

I understand that it is my responsibility to seek medical treatment if a suspected concussion is reported to me. I understand that my child cannot return to practice/play until they are evaluated by an appropriate health care provide and provide written clearance from the health care provider to their coach. 

I understand concussions can have a serious effect on a young, developing brain and need to be addressed correctly. 

I have read the Sudden Cardiac Arrest information sheet. I understand that my child should stop activity/exercise immediately if they have any warning signs of sudden cardiac arrest. I understand it is recommended if my child has any warning signs of sudden cardiac arrest while exercising, they have a medical examination before exercising or returning to participation in their sport. I understand that I or my child should report a family history of heart problems or warning signs of sudden cardiac arrest to the healthcare provider doing the medical examination. 

I understand how to request at my cost the administration of an electrocardiogram, in addition to a comprehensive physical examination required to participate in a youth athletic activity. I understand the athletic director may be able to assist me. 

By typing my name below, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian.
 *
ATHLETE AGREEMENT As a parent/guardian and as an athlete it is important to recognize the signs, symptoms, and behaviors of concussions and sudden cardiac arrest.  By typing your name below, you are signing this form, you are stating that you have read the Department of Public Instruction’s (DPI) and the Wisconsin Interscholastic Athletic Association (WIAA) Concussion and Head Injury information sheet and Sudden Cardiac Arrest Information sheet. 

Athlete Agreement: 
I have read the Concussion and Head Injury Information sheet. I have had the opportunity to read more information on concussions on the Centers for Disease Control and Prevention’s (CDC) websites. I understand what a concussion is and how it may be caused. I also understand the common signs, symptoms, and behaviors. I understand the importance of reporting a suspected concussion to my coaches and my parents/guardian. 

I understand that I must be removed from practice/play if a concussion is suspected. I understand that I must be evaluated by an appropriate health care provider and provide to my coach written clearance to participate in the activity from the health care provider before I may return to practice/play. 

I understand that after a head injury my brain needs time to heal and that it may not heal properly if I return to practice/play too soon. 

I have read the Sudden Cardiac Arrest Information sheet. I understand that I should stop activity/exercise immediately if I have any warning signs of sudden cardiac arrest and report the symptoms to my coaches and my parents/guardians.   

By typing my name below, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian.
 *
Todays Date: *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms