SportsEngine Registration: Soderville/Blaine Athletic Association

Concussion Proof of Certification

Please take the Free Concussion Certification Test found here:
http://www.cdc.gov/concussion/HeadsUp/online_training.html
Return here to submit your certification information

First Name:*

Last Name:*

Address 1:*

Address 2:

City:*

State/Province:*

Zip:*

Email:*

Phone Number 1:*

Phone Number 2:

Team Affiliation:

Did you pass the concussion test?:*

Please Upload a Copy of Your Certificate:

You are required to keep a copy of this certificate to support future auditing

Date Test was Completed:*

Electronic Signature:*

By completing this form you are certifying that all of the above information is correct to the best of your knowledge.