RELEASE OF INFORMATION:
AthletiCo and Midwest Center for Concussion Care may release ImPACT™ results and health information to my child’s
primary care physician, neurologist, and other treating healthcare professionals as needed to meet my child’s healthcare
needs. I agree that health information and test data may also be released to my child’s teachers, coaches, guidance
counselors and other school officials for purposes of determining return to play status and/or providing temporary
academic modifications when necessary.