PARENT / GUARDIAN CONCUSSION 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 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.
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.