MM/DD/YYYY

Select an Upper School Sport

Concussion and ImPACT Information
  • I have read the ImPACT letter (linked on this page) and understand its contents.
  • I have been given an opportunity to ask questions, and all questions have been answered to my satisfaction.
  • A note from another doctor does not guarantee my daughter may participate in athletics. My daughter must also be cleared by St. Mary's Athletic Trainer.
  • I understand that general information about the test data may be provided to my daughter's advisor and teachers for the purpose of providing temporary academic modifications, if necessary.
  • I give my daughter permission to participate in the ImPACT Concussion Management Program.
  • I give permission for St. Mary's Athletic Trainer to review my daughter's ImPACT results.
  • I authorize St. Mary's to release my daughter's ImPACT test results to my daughter, parents and guardians, and the physician indicated in your daughter's online Health record.

Travel Permission

Athletic participation will include travel in school-contracted vehicles, school buses, and personal vehicles. In addition, students may be escorted on foot to our home facilities. No travel will be permitted other than in these types of vehicles; however, all travel includes serious risk of injury. Please mark that travel is permitted below.

If you choose no, please make alternate travel arrangements for your daughter.​​

Max file size: 10 MBPlease upload completed athletics physical examination and consent forms if you have not done so already.​​​​​​