CONCUSSION/HEAD INJURY AND SUDDEN CARDIAC ARREST ACKNOWLEDGEMENT

The purpose of the Acknowledgement form is to confirm that you have read and understand the information provided to you by the WHSBLA related to potential Concussion/Head Injury and Sudden Cardiac Arrest (SCA) occurring during participation in athletic programs.

I, ____________________________as a student at ,____________________________,

And I __________________________________as the parent / legal guardian of

_______________________________have read and understand the information material

provided to us related to Concussion / Head Injury and Sudden Cardiac Arrest (SCA)

during participation in athletic programs and understand its contents and warnings.

_________________________________                   ____________________________
Signature of Student / Athlete                                                    Date

_________________________________                   ____________________________
Signature of Parent / Legal Guardian                                        Date

__________We were provided a copy of the Information Sheet for Parents/Legal Guardians and Athletes: Concussion/Head Injury and Sudden Cardiac Arrest (SCA).

Reference: SB 5083
HB 1824 (RCW 28A.600 & RCS 4.24.660)
7/2015