Common use of Concussions Clause in Contracts

Concussions. Have you ever had a head injury or concussion? Yes No If yes, when (date): Have you had more than one head injury or concussion? Yes No If yes, how many? Have you ever had a blow to the head that caused confusion, prolonged headache, or memory loss? As the parent or legal guardian of the above named student athlete, I give my permission for his/her participation in athletic events and the physical evaluation for that participation. I grant permission for treatment deemed necessary for a condition arising during participation in these events, including medical or surgical treatment that is recommended by a medical doctor. I grant permission to nurses, trainers, coaches, doctors or those under their direction who are part of the athletic injury prevention or treatment, to have access to necessary medical information. I know that the risk of injury to my child/▇▇▇▇ comes with participation in sports and during travel to and from play and practice. My signature indicates that to the best of my knowledge, my answers to the above questions are complete and correct. Signature of athlete Signature of parent/guardian Date Date

Concussions. Have you ever had a head injury or concussion? Yes No If yes, when (date): Have you had more than one head injury or concussion? Yes No If yes, how many? Have you ever had a blow to the head that caused confusion, prolonged headache, or memory loss? Yes No As the parent or legal guardian of the above named student athlete, I give my permission for his/her participation in athletic events and the physical evaluation for that participation. I grant permission for treatment deemed necessary for a condition arising during participation in these events, including medical or surgical treatment that is recommended by a medical doctor. I grant permission to nurses, trainers, coaches, doctors or those under their direction who are part of the athletic injury prevention or treatment, to have access to necessary medical information. I know that the risk of injury to my child/▇▇▇▇ comes with participation in sports and during travel to and from play and practice. My signature indicates that to the best of my knowledge, my answers to the above questions are complete and correct. Signature of athlete Date Signature of parent/guardian Date Student’s Name Today’s Date