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Acknowledgment of Receipt of Concussion Information Sheet
Pursuant to California Health and Safety Code §124235, a concussion and head injury information sheet shall be given by each youth sports organization offering an athletic program to each athlete in that program. The information sheet shall be signed and returned by the athlete and, if the athlete is 17 years of age or younger, shall also be signed by the athlete’s parent or guardian before the athlete initiates practice or competition. The USA Swimming Concussion Information Sheet (three pages) is attached to this acknowledgment.
Please note, the information contained in the Swimming Concussion Information Sheet and this Acknowledgment is not medical advice and is no substitute for it.
I hereby acknowledge that I have received the USA Swimming Concussion Information from QuickSilver Swimming.
I have read and understand its contents.
I also acknowledge that if I have any questions regarding the signs or symptoms of a concussion or other head injuries, the need to seek medical attention and the protocol for returning to daily activities, school and the swimming pool, I will consult with a licensed health care provider.