Parent & Athlete Agreement

PARENT & ATHLETE AGREEMENT

Related to Concussion Law 2011 – Wisconsin Act 172


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. This form must be completed for every sports season and every youth athletic organization the athlete is involved with.


Parent Agreement:

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/Guardian Signature Date

Athlete Agreement:

I have read the Athlete Concussion and Head Injury Information 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 Date

Questions and Contact Information

Related to Concussion Law 2011 – Wisconsin Act 172

Check all that apply (This document must be completed at the beginning of every athletic season)

I participate in:

 Football Baseball/Softball Basketball Hockey Soccer Golf Volleyball Wrestling Track & Field Cross Country Cheerleading Skiing/Snowboarding Gymnastics Tennis Swimming & Diving

  1. Have you ever had a concussion?  Yes No   If yes, how many?
  2. Have you ever experienced concussion symptoms? Yes No   Did you report them?  Yes No

Emergency Contacts:


Please complete this form and return to the person operating the youth athletic activity.