ACHILLE

CONCUSSION/HEAD INJURY, HEAT ILLNESS,

& SUDDEN CARDIAC ARREST

ACKNOWLEDGEMENT

ACHILLE SCHOOL

In compliance with Oklahoma Statute Section 24-155 of Title 70, this acknowledgement from is to confirm that you have read and understand the FACT SHEETS provided

to you by ACHILLE SCHOOL related to potential concussions,

head injuries, heat illness, and sudden cardiac arrest

occurring during participation in athletics.

“I, _______________________________, as a student -athlete who participates in

                                                                   (PLEASE PRINT STUDENT ATHLETE’S NAME)

ACHILLE ATHLETICS and I, ________________________________ as a parent/legal guardian, have read

                                                                                                            (PLEASE PRINT PARENT/LEGAL GUARDIAN’S NAME)

the information provided, related to concussions, head injuries, heat illness, and sudden cardiac arrest occurring during participation in athletic programs and understand the content and warnings.”

___________________________________________________________________________________08-10-17_________

                                            STUDENT-ATHLETE SIGNATURE                                                                                                                                                         DATE

___________________________________________________________________________________08-10-17_________

                                          PARENT/LEGAL GUARDIAN  SIGNATURE                                                                                                                                             DATE

ACHILLE PUBLIC SCHOOL

101 N. 5th Ave

ACHILLE, OK 74720

580-283-3775