Effective January 1, 2012, a new law ( Education Code Section
49475), requires the student and parent/legal guardian must sign
this Concussion Head Injury Information Sheet before a Student
may try-out, practice, or compete in any District-sponsored
extracurricular athletic program, including interscholastic,
intramural, or other sport or recreation programs (including
cheer/dance teams and band), but excluding physical education
courses for credit.
Coach or other removes student from activity and completes form
and gives to student or parent. Included medical release must be
obtained before student can return to play. Optional
to use for other serious injuries.
User is a nonprofit organization, or a club or association (other
than a public agency) organized to promote youth and school
activities, which will not engage in fund raising activities not
designed to benefit your or public school activities on School
One Student Activity Waiver Form is required for EACH activity
and signed by a parent and student. This form is used for
extracurricular activities or clubs such as a language club,
speech and debate, chess club. This form is available in
other languages by calling Risk Management Office.
Use this universal form when reporting an incident or student
injury. Reminder: this is confidential SCUSD information
and cannot be released to parent or other party. Please
call Risk Management if you have any questions at 643-9421.