Looking for a Florida Legal Forms And Templates? Download it for free!

Post Head Injury/concussion Initial Return To Participation - Florida High School Athletic Association Page 2

AT18

Florida High School Athletic Association

Created 06/12

Post Head Injury/Concussion Initial Return to Participation

(Page 2 of 2)

This completed form must be kept on file at the student-athlete’s school.

Return to Competition Affidavit

Student-Athlete’s Name: _______________________________________________________________________________________

Date of Birth: _____/_____/________ Injury Date: _____/_____/________

Formal Diagnosis: ____________________________________________________________________________________________

School: _____________________________________________________________________________________________________

Sport: ______________________________________________________________________________________________________

I certify that I have reviewed the signed graded return to activity protocol provided to me on behalf of the athlete named above.

This athlete is cleared for a complete return to full-contact physical activity as of _____/_____/________.

This student-athlete is instructed to stop play immediately and notify a parent, licensed athletic trainer or

coach and to refrain from activity should his/her symptoms return.

Physician Name: _____________________________________________________________________________________________

Physician Signature:_____________________________________________________ License No.: ___________________________

Phone: (_______) ____________________ Fax: (_______) ____________________ E-mail: _______________________________

Date: _____/_____/________

– 2 –

Post Head Injury/concussion Initial Return To Participation - Florida High School Athletic Association Page 2