I the athlete: herby acknowledge having been provided with education about the signs, symptoms and risks of sport related concussion and understand the importance of, and acknowledge my responsibility of immediately reporting any signs or symptoms of head injury/concussion to my coaches, parent(s) / guardians(s) and sports medicine staff. I understand that there is a possibility that participation my sport may result in a head injury and/or concussion. By signing below, I acknowledge that my institution has provided me with specific educational materials on what a concussion is and given me an opportunity to ask questions about areas and issues that are not clear to me on this issue.

I the parent / guardian of the athlete named above, hereby acknowledge having received education about the signs, symptoms, and risks of sport related concussion. I acknowledge the Badger East Youth Football League and Forward Youth Football League Policy that any student-athlete showing signs, symptoms or behaviors consistent with a concussion shall be removed immediately from practice or competition and evaluated by available medical personnel, Licensed Athletic Trainer, or other health care professional with specific training in the evaluation and management of concussion. I understand any athlete removed from practice or competition for concern of a concussion WILL NOT return to participation on the day of injury and shall not return to any activity until he or she is evaluated by a health care professional and receives a written clearance to participate in the activity from the health care provider.