Rise Academy of Arts CONCUSSION/INJURY RETURN TO PLAY FORM

Rise Academy of Arts require that an athlete be removed
from any training, practice or competition if they exhibit any signs, symptoms or behaviors consistent with a concussion, are suspected of sustaining a concussion, or an injury occurs that results in pain when touched or when the athlete can not bear weight. The athlete should not return to physical activity until he or she has
been evaluated by a qualified medical provider who has provided written clearance to return to sports.
This form is to be used after an athlete has been removed from athletic activity due to a suspected
concussion or injury and must be signed by their medical provider in order to return without restriction to training,
practice or competition. Forms that are signed by only the Parent/Gaurdian will result in an athlete returning with restrictions to training at the attending coaches discretion.

Athlete's Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Email

example@example.com

Athlete's Date of Birth*

Date

Date of Suspected Concussion/Injury*

Date

Location Of Injury*

Injury Signs/Symptoms*

Print Health Care Professional Name

First NameLast Name

License Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

I HEREBY AUTHORIZE THE NAMED ABOVE ATHLETE TO RETURN TO NORMAL ATHLETIC ACTIVITY FOR FULL PARTICIPATION WITHOUT RESTRICTION

Medical Professional Signature

Date

I, First Name Last Name the undersigned parent/guardian of the minor athlete First Name Last Name consent to my minor athlete returning to restricted participation in activities at Rise Academy of Arts and At Events Attended by Rise Academy of Arts and or one of their competitive teams. I fully understand my/minor’s participation in activities after a suspected concussion/injury with or without a medical release from a professional may involve risk of worsening an injury, serious injury or death, including losses which may result not only from my/minor’s own actions, inactions or negligence, but also from the actions, inactions, or negligence of others. This includes all activities within Rise Academy of Arts and Attended by Rise Academy of Arts/Competitive Teams. I understand that if I have any risk concerns regarding participation, I should discuss the risks associated with my/minor’s participation with a medical professional and the Rise Academy Owners or Coaching Staff, before I sign this document and before my minor returns to activities.

In consideration of allowing Minor Participant to return to Rise Academy of Arts, I hereby release and hold harmless the Released Parties, of and from, and do discharge and waive, any and all claims, demands, losses, damages, and liabilities that I may have or sustain with respect to any and all damage and/or injury, of any type, arising from Minor Participanting at Rise Acadeny of Arts/Competitions Teams/Events. I also agree that if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in full force and effect.
I certify that my/minor is in good health and have no physical condition that would prevent them from returning to activities at and with Rise Academy of Arts/Competition Teams. Furthermore, I agree to use my/minor’s personal medical
insurance as a primary medical coverage payment if accident or injury occurs. I consent to emergency medical treatment in the event such care is required.

Parent/Guardian Printed Name*

First NameLast Name

Parent/Guardian Signature*

Date*

Date

The undersigned parent/guardian further agrees to indemnify, save and hold harmless the Released Parties from any and all claims, demands, losses, damages and liabilities for indemnities, contribution or otherwise with respect to any damage and/or injury, of any type, arising from Minor Participanting at/on/in Rise Academy of Arts/Competition Teams practices/training/events.

Parent/Guardian Printed Name*

First NameLast Name

Parent/Guardian Signature*

Date*

Date