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