Healthcare Provider List Registration Form — Alaska School Activities Association

Rationale
ASAA shall maintain a list of those healthcare providers in Alaska who self-verify that they meet the requirements stated in ASAA’s Handbook (State Championships Policies Section, page 98) and are qualified under AS 14.30.142 (see enclosed House Bill 15 and Senate Bill 119), and are available to evaluate and manage student athletes with suspected or actual concussions. This list is provided for the convenience of student-athletes, their parents, and their coaches who are seeking concussion care.

PROFESSIONAL DESIGNATION
NAME
First Last
BUSINESS NAME
BUSINESS ADDRESS
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
BUSINESS PHONE
EMAIL ADDRESS

Note: Your email address will not be listed on our website. We need it to send you a copy of your submission and for future communications.
Disclaimer
The Healthcare Provider List is not intended to be all-inclusive and does not imply endorsement or verification of qualifications by ASAA or its Sports Medicine Advisory Committee (SMAC).