Mishicot School District Sports Concussion Management Plan APPENDIX A: Statement Acknowledging Recelpt of Education and Responsibility to report signs or Symptoms of concussion to be included as part of the “Participant and Parental Disclosure and Consent Document”. “ of Mishicot High School SudenAlee Rone hereby acknowledge having received education about the signs, symptoms, and risks of sport related ‘concussion. | also acknowledge my responsibility to report to my coaches, parent(s}/guardian(s| any signs ‘or symptoms of a concussion. ignanire ond proto name of walentahite Baie |, the parent/guardian of the student athlete named above, hereby acknowledge having received ‘education about the signs, symptoms, and risks of sport related concussion. Flame and pinta wane ofparenigartan Baie WISCONSIN INTERSCHOLASTIC ATHLETIC ASSOCIATION ALTERNATE YEAR ATHLETIC PERMIT CARD Physical Date SCHOOL YEAR 20-2. nae nave ATE OF BIRTH _ tat Fiat id na ‘iy Physician — Famty Oomist jE Mave of Pvsle hmrance Cater EE Telephone Suber Waray Nae (rin suc) 1 Soe amy rio rt ne net se pa arena en Fe ar WA as sie ais eae na Healy rane atby esd Rsunaby ht 008 wn tpi paged Reese eco taoes se TPA, lo ssn ros sour, ree sovery ase prea ard oe ay aes poker ha ayo stg an mischae 2o Sn te Ne de Sy a ee Sl ‘of iratmes, emergency cans and injury reccrd-kasping. be ee 4, iivraanmandlThtisumaien lg ures loa td psotnd mascaon be age sab Pant Yon enor fe easy nites aie compen ea Ses a fea, ce yn mac a De gang cs SIGNATURE OF ae ome STUNENTS PARTICIPATING We IWTERSCHOLASTIC ATHLETICS MUST HAVE THIS ALTERRATE YEAR GARD N FRE AT THEIR SCHOOL PRIOR TD PRACTIE On PARTITION