CONSENT FOR
COGNITIVE TESTING and RELEASE OF INFORMATION
I
give my permission for (name of child) __________________________________
(child’s date of birth)
_____________________________
to
have a pre-concussion ImPACT (Immediate PRE-concussion Assessment and
Cognitive Testing) administered at Hanover High School. I understand that my
child may need to be tested more than once, depending upon the results of the
test, as compared to my child’s baseline test, which is on file at HHS. I understand
there is no charge for the testing.
Hanover High School may release the ImPACT (Immediate
Pre-concussion Assessment and Cognitive Testing) results to my child’s primary
care physician, neurologist, or other treating physician, as indicated below.
I understand that general information about the test data
may be provided to my child’s guidance counselor and teachers, for the purposes
of providing temporary academic modifications, if necessary.
Name
of parent or guardian: _______________________________________________
Signature
of parent or guardian: _____________________________________________
Date:
________________________________________
PLEASE PRINT THE
FOLLOWING INFORMATION:
Name
of doctor: _____________________________________
Name
of practice or group: _____________________________________
Phone
number: _____________________________________
Student’s
home address:___________________________________________________________
Parent
or guardian phone numbers (please indicate preferred contact number & time
if necessary):
_________________________
(H) ____________________________ (W)
_________________________
(cell)
7/2013
