Concussion Risk Liability Waiver

Concussion Risk Liability Waiver
Please complete this form to acknowledge and accept the risks associated with concussion during participation.
Participant's Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name
First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Emergency Contact
Please specify the activity or event you will be participating in:
Do you have any known medical conditions or history of concussions that the organizers should be aware of?
If yes, please provide details:
Participant or Guardian Signature
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