Concussion Report

Concussion Report
Dear CA Parents/Guardians,

If your child sustains a suspected or diagnosed concussion, whether or not they are at a CA event, it is of vital importance that you notify school personnel using the form below. Please fill it out as completely as possible. For more information about our CA's concussion protocols, please review this communication.

Thank you.
Student Name*

First NameLast Name
Parent Name*

First NameLast Name
Parent Email*
example@example.com
Parent Phone Number*
Please enter a valid phone number.
Division*
Grade*
Advisor/Classroom Teacher*
Current Sports Teams (if any)
Date of Injury*

MonthDayYear
Date
Details of Injury*
Is concussion:*

SuspectedDiagnosed by a Health Care Provider
What symptoms have been reported or observed?*
Has the student been evaluated by a health care provider?*

Yes (please provide documentation below)Not yet
Please upload any documentation from the health care provider

Cancelof
Should be Empty: