Maryland State Department Of Education Concussion Awareness Parent/student-Athlete Acknowledgement Statement
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12For official use only:
Name of Athlete_____________________
Sport/season________________________
Date Received_______________________
Concussion Awareness
Parent/Student-Athlete Acknowledgement Statement
I ______________________________, the parent/guardian of ______________________,
Parent/Guardian
Name of Student-Athlete
acknowledge that I have received information on all of the following:
The definition of a concussion
The signs and symptoms of a concussion to observe for or that may be reported by my athlete
How to help my athlete prevent a concussion
What to do if I think my athlete has a concussion, specifically, to seek medical attention right
away, keep my athlete out of play, tell the coach about a recent concussion, and report any
concussion and/or symptoms to the school nurse.
Parent/Guardian_________________ Parent/Guardian___________________ Date ________
PRINT NAME
SIGNATURE
Student Athlete__________________ Student Athlete____________________ Date ________
PRINT NAME
SIGNATURE
It’s better to miss one game than the whole season.
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