Jerome Joint School District No. 261

STUDENTS 3505F1

ACKNOWLEDGMENT OF RECEIPT OF CONCUSSION GUIDELINES

Parent’s/Guardian’s Signature

I, (print name)_______________________________, acknowledge that I am the parent or guardian of the student (below),

that I have received from the District information related student athlete concussions, including information from the State

Department of Education, the Idaho High School Activities Association, and District Policy 3505, and have had the

opportunity to review and have reviewed such information. I understand that participation in school athletics leagues or

sports is dangerous, and hereby agree to waive all liability against ______________________________ School District, No.

____, its employees, agents, and trustees, related to any injury or damages that my student may experience or incur as a

result of participation in such school athletics leagues or sports.

______________________________________ ______________________________

Signature Date

Student’s Signature

I, (print name)_______________________________, acknowledge that I am a student of

_______________________________ School District, No. ____, or otherwise am allowed to participate in school athletics leagues or sports, that I have received from the District information related student athlete concussions, including information from the State Department of Education, the Idaho High School Activities Association, and District Policy 3505,

and have had the opportunity to review and have reviewed such information. I understand that participation in school

athletics leagues or sports is dangerous, and accept the risk of the potential consequences of such dangers.

______________________________________ ______________________________

Signature Date

NOTE: Both signature lines must be filled in and this form must be provided to the District prior to the student athlete

participating in any school athletic leagues or sports.

Policy History:

Adopted on: 07/24/2012