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HEALTH SERVICES 1200 South Barr Street Fort Wayne, IN 46802 Concussion and Sudden Cardiac Arrest Acknowledgement & Signature Form Student Athletes Name (Please Print): Sport Participating In: Date:
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Make sure to gather all necessary information and forms. This may include medical history, contact information, and consent forms.
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Carefully read and understand the instructions provided with the forms. Pay attention to any specific requirements or guidelines.
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Start by filling out personal information such as name, date of birth, and contact details.
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Proceed to provide details about any previous concussions or cardiac conditions, if applicable. This may include dates, symptoms experienced, and treatments received.
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If you have undergone any medical tests or evaluations related to concussions or cardiac health, make sure to include those results, if required.
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Who needs concussion and sudden cardiac?

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Athletes: Concussion and sudden cardiac assessment and reporting are crucial for athletes participating in sports activities. It helps to ensure their safety and well-being during training and competitions.
02
Students: Many schools and educational institutions require concussion and sudden cardiac screenings for students, particularly those involved in physical education, sports teams, or extracurricular activities.
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Individuals with relevant medical history: People who have previously experienced concussions or have underlying cardiac conditions should undergo regular screenings to monitor their health and manage potential risks.
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Parents and Guardians: It is essential for parents and guardians of children involved in sports or physical activities to be aware of the processes and requirements for filling out concussion and sudden cardiac forms. This enables them to provide accurate information and support the well-being of their children.
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