Montclair United Soccer Club

COACH/TRAINER CONCUSSION EDUCATION COMPLIANCE FORM

In order to help protect the student athletes of New Jersey, the NJSIAA has mandated that all athletes, parents/guardians and coaches follow the NJSIAA Concussion Policy.

I,________________________, (coach/trainer) of the_______________________(team or program)

in the _________________________ (age group) have taken the online "Heads Up" course at:

http://www.cdc.gov/concussion/HeadsUp/online_training.html

on ________________________(date)

and have satisfied the requirements of the coursework.

____________________________________________ (signature)

____________________________________________ (date)

Please send this form along with a copy of your online training certificate via:

FAX - (973) 547-3344

EMAIL - [email protected]

or drop off/mail forms to:

Debra David (669 Grove Street)

Thank you.

MUSC