Concussion and Injury Reporting Acknowledgement

Name

First NameLast Name

Email

example@example.com

After reading the NCAA Concussion and Emmaus Sports Medicine Concussion Fact Sheets (see below), I am aware of the following:

A concussion is a brain injury. You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury.

I will notify my athletic trainer or physician of any and all symptoms associated with a head injury (diagnosed or potential). I am responsible for reporting to my athletic trainer or physician.

I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion-related symptoms.

If I suspect a teammate has a concussion, I am responsible for reporting the injury to my athletic trainer or team physician.

A concussion can affect my ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance.

Following a concussion, the brain needs time to heal. You are much more likely to have a repeat concussion if you return to play before the symptoms resolve.

If diagnosed with a concussion, I will report symptoms each day until I am cleared for full activity by the sports medicine staff. Failure to do so may prolong my symptoms and increase the risk of further brain injury that may result in severe disability or death if a second blow to the head is sustained before I am fully recovered from the concussion.

I have read and understand the NCAA Concussion and Emmaus Sports Medicine Concussion Fact Sheets.

I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician.

Participant Signature

Date