Step-2-Concussion-Statement

PART 1: Student athletes should check the two boxes at the top left of the page, provided they understand the Concussion Fact Sheet. Ask your coach if you have any questions.

PART 2: Student athletes and Parents need to complete this form. Students should place their initials in the Student Column and Parents should place their initials in the Parent Column.

PART 3: Student Athletes and Parents should PRINT their names at the bottom of the page.Then Student Athletes and Parents should SIGN their names and place the date in the required spaces.

PART 1:

PART 2:

PART 3:

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Student SIGN name and put DATE here

Student PRINT name here

Parent SIGN name and put DATE here

Parent PRINT name here