Student-Athlete Concussion/Injury Statement
Please Read Carefully & Understand Before You Sign
I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer/athletic healthcare provider and/or team physician.
Check To Agree
I have read and understand the NCAA Concussion Fact Sheet below.
Check To Agree
I have viewed the Concussion Video below.
Check To Agree
After reading the NCAA Concussion Fact Sheet and viewing the concussion video, I am aware of the following information (check all that apply):
A concussion is a brain injury, which I am responsible for reporting to my athletic trainer/athletic health care provider or team physician.
A concussion can affect my ability to perform everyday activities, affect reaction time, balance, sleep, and classroom performance.
You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after injury.
If I suspect a teammate has a concussion, I am responsible for reporting the injury to the athletic trainer/athletic health care provider or team physician.
I will not return to practice or play in a contest if I have received a blow to the head or body that results in concussion related symptoms.
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 your symptoms resolve.
In rare cases, repeat concussion can cause permanent brain damage, and even death.
Attestation
I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. I have read the above information noted here by reference, and I understand the risk of injury or death. I understand that by participating in intercollegiate athletics I am subject to the possibility of injury or death as outlined above.
Student-Athlete Name
First Name
Last Name
Head Coach Email
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PrestonW@bigbend.edu
JasonH@bigbend.edu
ChaseT@bigbend.edu
KyleeB@bigbend.edu
AlexaM@bigbend.edu
DesireeZ@bigbend.edu
DaviaireD@bigbend.edu
Student-Athlete Email
*
example@example.com
Student-Athlete Signature
Clear
Signature of Parent/Legal Guardian (If Under 18)
Clear
Sport
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Women's Basketball
Men's Basketball
Women's Wrestling
Men's Wrestling
Baseball
Softball
Volleyball
Date
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