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2. ACKNOWLEDGEMENT THAT PARTICPANT HAS READ CDC HEADS UP DOCUMENT*

   1. Click Here to Acknowledge

   This form is used as acknowledgement that the child/athlete and parent/guardian have discussed the risks of concussion and other serious brain injuries, as well as ways to protect against such injuries, as described in the CDC HEADS UP information sheet.
4. Date Signed*
   Date Signed
6. Name of Child/Athlete*
7. Name of Parent/Legal Guardian*
9. Digital Signature of Athlete*
   I learned about concussion from the CDC HEADS UP fact sheet and talked with my parent or coach about what to do if I have a concussion or other serious brain injury. By typing your first and last name above, you are agreeing and acknowledging that your digital signature is valid and binding upon you to the same force and effect as a handwritten signature.
11. Digital Signature of Parent/Legal Guardian*
    I have read the CDC HEADS UP fact sheet for parents on concussion with my child or teen, and talked about what to do if they have a concussion or other serious brain injury. By typing your first and last name above, you are agreeing and acknowledging that your digital signature is valid and binding upon you to the same force and effect as a handwritten signature.
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13. 1. Receive an email copy of this form.
14. Email address

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