HUDSON VALLEY COMMUNITY COLLEGE
KIDS ON CAMPUS CONCUSSION EDUCATION AND MANAGEMENT
ACKNOWLEDGEMENT FORM
Parent/Guardian Waiver
I UNDERSTAND AND ACKNOWLEDGE, as a Parent or Legal Guardian and as a Participant, it is
important to recognize the signs, symptoms and behaviors of concussions. By signing this form I
am stating that I understand the importance of recognizing and responding to the signs, symptoms
and behaviors of a concussion or head injury.
I HAVE READ the Concussion Information Sheet and understand what a concussion is and how it
may be caused. I also understand the common signs, symptoms and behaviors. I agree that the
Participant must be removed from program/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 and that the Participant cannot return to program/play for 24 hours and must provide
written clearance from a licensed physician to the Athletic Trainer or Director of Community &
Professional Education. I understand the possible consequences of the Participant returning to
program/play too soon.
________________________________________________
Name of Participant (printed)
________________________________________________
Name of Parent/Guardian (printed)
X
Signature of Parent/Guardian
/ _/
Date
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