Student/athlete & Parent or Guardian Safety Training and Concussion Protocol Acknowledgement Form


I have viewed the UIL Safety Training video and have been provided training in recognizing symptoms of catastrophic injuries, including head and neck injuries, concussions, asthma attacks, heatstroke, cardiac arrest and injuries requiring use of an AED, the risks of using nutritional supplements. In addition, I have been provided information pertaining to Stacey Concussion Protocol.



Date:  ____/____/2011

  Mo.   Day


Student/athlete name: ________________________________

  (please print)


Student/athlete signature:________________________________



Parent or guardian name: ________________________________

    (please print)


Parent or guardian signature:________________________________




*you may print this page to complete and return to Stacey Athletic Department or you may obtain this form from Stacey staff