Tualatin Valley Youth Football (Westview Youth Football)

Baseline Concussion Test

I hereby acknowledge that ______________________________________________________ (Print player's name)  has completed a Baseline Concussion or Pre-Test on _____________________________________________ (date) at ___________________________________________________ (Clinic/Office).

Doctor/Clinic Official/Athletic Trainer or Director (name) ______________________________________________

Doctor/Clinic Official/Athletic Trainer or Director (signature) ___________________________________________

Doctor/Clinic Official/Athletic Trainer or Director (Phone) _____________________________________________

I understand all of the above information to be accurate. I, as parent/guardian of said player/minor hereby give permission for said minor to participate in any and all activities sponsored by Tualatin Valley Youth Football.

Parent/Guardian (Please print) ____________________________________________________

Parent/Guardian (Signature) ______________________________________________________

Date ______________________