Gooding Joint School District No. 231
AUTHORIZATION TO RETURN TO PLAY OR PARTICIPATE IN STUDENT SPORTS
I hereby state that I am a:
Physician licensed pursuant to chapter 18, title 54, Idaho Code.
Physician’s assistant licensed pursuant to chapter 18, title 54, Idaho Code.
Advanced practice nurse licensed under section 54-1409, Idaho Code.
A licensed health care professional trained in the evaluation and management of concussions who is supervised by a directing physician licensed under chapter 18, title 54, Idaho Code. My directing physician is , and his/her license number is
, and address is .
I further state that I have met with (hereinafter referred to as “student athlete”) to evaluate the student athlete for a concussion. I have discussed with the student athlete the potential ramifications of continuing to play sports after having received a concussion or exhibiting concussion like symptoms. I am satisfied that the student athlete can return to play and/or participate in school athletic leagues or sports without significant likelihood of danger or injury, and I therefore authorize student athlete to return to play and/or participation in school athletic leagues or sports.
Signature Date License No.
Signature of Directing Physician Date
(if signed by a Licensed Health Care Professional)
Adopted on: July 17, 2012 Revised on: