Athlete Concussion Release form

Please read Concussion information available at DPI website before completing this form 
Wisconsin Department of Public Instruction
125 South Webster Street, PO Box 7841, Madison, WI 53707-7841
Phone         608-266-3390, Toll free     800-441-4563
Web site http://www.dpi.wi.gov

Parent & Athlete Agreement

As a Parent and as an Athlete it is important to recognize the signs, symptoms, and behaviors of concussions. By signing this form you are stating that you understand the importance of recognizing and responding to the signs, symptoms, and behaviors of a concussion or head injury.

Parent Agreement: 

Parent Name: *
Parent E-mail: *

I  have read the Parent Concussion and Head Injury Information and 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 providing written clearance from an appropriate health care provider to his/her coach.

 I understand the possible consequences of my child returning to practice/play too soon. 

Parent Signature: *
Today's Date:

Athlete Agreement: 

Athlete Name: *

I have read the Athlete Concussion and Head InjuryInformation and understand what a concussion is and how it may be caused.  

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 provide written clearance from an appropriate health care provider to my coach before returning to practice/play. 

I understand the possible consequence of returning to practice/play too soon and that my brain needs time to heal. 

Athlete Signature: *
Today's_Date:

Questions and Contact Information

Athlete_Name: *
Address: *
Phone: *
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E-mail:
Age: *
School:
School District:
Sports I participate in:

Name of current team - West Side Swim Club Swim & Dive

Have you ever had a concussion? *
If yes how many?
Have you ever experienced concussion symptoms> *
If yes did you report them?

Emergency Contacts

Name 1: *
Relationship:
Phone 1: *
-
Name 2:
Relationship 2:
Phone 2:
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