Concussion Acknowledgement Form

Please download and read the Concussion Fact Sheet for Parents and Athletes, then fill out the form below.

In order for Camp Shutout to comply with all aspects of Wisconsin Act 172, the following statement of acknowledgement must be signed and returned.
Parent Statement
I have read the Concussion Fact Sheet for Parents and Athletes and further acknowledge, agree, and understand the signs and symptoms of concussion and 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 acknowledge, agree, and understand that it is my responsibility to seek medical treatment if a suspected concussion is reported to me.

I acknowledge, agree, and understand that my child cannot return to practice/play until providing written clearance from an appropriate health care provider to his/her coach.

I acknowledge, agree, and understand the possible consequences of my child returning to practice/play too soon.
Athlete's Name*
First Last
Parent/Guardian Name*
First Last
Signature*
Date*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Parent Statement