Consent for Administration of ImPACT Assessment,

Release of Information and Concussion and Head Injury Form

The purpose of this form is to confirm receipt of the Holton Arm’s School (the “School”) “Concussions and Head Injuries” policy and other information relating to concussions and head injuries that may occur during participation in athletic programs or physical education classes and to provide the Holton Arm’s School permission to administer the ImPACT on my daughter.

I am the parent/legal guardian of the above named child.  I confirm through my signature below that:

1.      I have received a copy of the School’s Concussion Policy and the Center for Disease Controls “Head’s Up” concussion form.

2.      I will seek proper medical attention if I suspect that my daughter has suffered a concussion.

3.      I will report a to the school nurse, athletic trainer, and coach/physical education teacher if my daughter suffers a concussion or other head injury.

4.      I will comply with the School’s Concussion Policy and agree that it is the School’s sole and exclusive right to determine when my daughter can participate in sports and or athletics after a concussion or suspected concussion.

5.      I understand and agree that it is my responsibility to ensure my daughter complies with the protocol provided by the School in the case of a concussion.

6.      I give permission to the School to treat my daughter during games, activities and other events.  

7.      I give the School permission to administer the ImPACT at times as determined by the School including but not limited to a baseline test, during the recovery from a concussion and prior to returning to play.

8.      I am aware that the initial administration of the ImPACT will provide a baseline which will be kept on file at the School and give permission to the School to utilize the results of all ImPACT as needed.

9.      I give permission for the School to release  any and all  ImPACT results to my child’s primary care physician, neurologist, or other treating physician(s).

10.  I give permission to the School to release general information about the ImPACT data to my child’s guidance counselor and teachers, for the purposes of providing temporary academic modifications, if necessary.

11.  I agree to work collaboratively with the School if academic accommodations are needed.

I have carefully read this Consent for Administration of ImPACT Assessment, Release of Information and Concussion and Head Injury Form. My signature below serves as acknowledgment and agreement to the terms and provisions as described above.

please enter your full name

Please sign the form by clicking "SIGN" below. Your typed name will  serve as your signature for this form. The electronic signature and related fields are treated by The Holton-Arms School like a physical handwritten signature on a paper form as if actually signed by you in writing. Further, you agree that no certification authority or other third party verification is necessary to validate your electronic signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or any resulting contract between you and the School.