K
I
C
K
B
O
X
I
N
G
HOME
HOME
CONCUSSION DATA COLLECTION
EMail Us
info@wakocanada.org
Call Us
+905.681.9815
Kickboxing Ontario
Report Your Concussion
Athlete Name:
Athlete Age:
Gender
Please select
Female
Male
Other
Date of suspected concussion:
Time of suspected concussion:
Please select
Morning
Afternoon
Evening
Type of Sport Activity:
Please select
Competition
Training
Practice
Discipline:
Please select
Ring
Tatami
Type of Contact Resulting in Concussion:
Please select
Illegal Play
Unintentional Athlete on Athlete Contact
Intentional Athlete on Athlete Contact
Athlete on Playing Surface Contact
Athlete on Equipment Contact
Other
Date Physician or Nurse Practitioner Confirmed Concussion (if available):
Date Physician or Nurse Practitioner Cleared Athlete to Return to Sport (if available):
To prevent spam please answer the math question:
SUBMIT
By opting into the web form above you are providing the Government Of Ontario with important concussion information. All information is private and will only be used for concussion data reports only. No identifying data is collected.
