Concussion Form

Indicate your agreement by signing below. Keep a copy of the downloaded form for your records. *

I have received and read the Loudoun County Public Schools Student Athlete-Concussion Guidelines and grant my consent and permission for the student-athlete to participate in the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) program including baseline and testing for suspected concussions. Furthermore, I acknowledge, understand, and certify by my signature below that I agree to the protocols of the LCPS concussion program for the student-athlete’s best welfare and safe participation in sports for Loudoun County Public Schools.

Student Athlete Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name