Student-Athlete Post-Concussion Clearance Documentation

Student-Athlete Information

Name:

Date of Birth:

Grade:

School:

Sport:

Concussion Diagnosis

Date of Injury:

Date Diagnosed:

Medical Clearance

Physician/Provider Name:

Phone/Fax/Email:

Date Cleared:

Comments/Restrictions (if any):

Provider Signature

Signature:

Date: