PARENT/STUDENT AGREEMENT – Concussion Law – Wisconsin Act 172

As a parent and as a student, 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 school year in which your child will participate in any physical activity at school. This activity includes, but is not limited to: recess, physical education class, extracurricular sports, etc.
More detailed information regarding concussions can be found at:

Parent Agreement*

I have read the Parent Concussion and Head Injury Information

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/class if a concussion is reported to me. I understand that my child cannot return to practice/play/class until providing written clearance from an appropriate health care provider to his/her teacher or coach. I understand the possible consequences of my child returning to practice/play/class too soon.

Parent Name*

First Last

Student Name*

First Last

Parent Signature*

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Phone

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