Form E14-00395 - Sudden Cardiac Death Pamphlet Sign-Off Sheet
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1State of New Jersey
DEPARTMENT OF EDUCATION
Sudden Cardiac Death Pamphlet
Sign-Off Sheet
Name of School District:________________________________________________________________
Name of Local School: _________________________________________________________________
I/We acknowledge that we received and reviewed the Sudden Cardiac Death in Young Athletes pamphlet.
Student Signature: _____________________________________________________________________
Parent or Guardian
Signature:____________________________________________________________________________
Date:____________________________
New Jersey Department of Education 2014: pursuant to the Scholastic Student-Athlete Safety Act, P.L. 2013, c.71
E14 00395
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