Student-Athlete & Parent/Guardian - please read the attached fact sheets regarding concussion and sudden cardiac arrest and ensure that your student-athlete has also received and read these fact sheets. After reading these fact sheets, please ensure that you and your student-athlete sign this form.
Student-Athlete Concussion Fact Sheet
Parent/Guardian Concussion Fact Sheet
Student-Athlete Sudden Cardiac Arrest Fact Sheet
Parent/Guardian Sudden Cardiac Arrest Fact Sheet
IC 20-34-7 and IC 20-34-8 require schools to distribute information sheets to inform and educate student-athletes and their parents on the nature and risk of concussion, head injury and sudden cardiac arrest to student-athletes, including the risks of continuing to play after concussion or head injury. These laws require that each year, before beginning practice for an interscholastic sport, a student-athlete and the student athlete’s parents must be given an information sheet, and both must sign and return a form acknowledging receipt of the information to the student athlete’s coach.
IC 20-34-7 states that an interscholastic student-athlete, in grades 5-12, who is suspected of sustaining a concussion or head injury in a practice or game, shall be removed from play at the time of injury and may not return to play until the student-athlete has received a written clearance from a licensed health care provider trained in the evaluation and management of concussions and head injuries, and at least twenty-four hours have passed since the injury occurred.
IC 20-34-8 states that a student-athlete who is suspected of experiencing symptoms of sudden cardiac arrest shall be removed from play and may not return to play until the coach has received verbal permission from a parent or legal guardian for the student-athlete to return to play. Within twenty-four hours, this verbal permission must be replaced by a written statement from the parent or guardian.
By signing below you agree to the following:
Acknowledgement as a Student-Athlete
As a student-athlete, I have received and read both of the fact sheets regarding concussion and sudden cardiac arrest. I understand the nature and risk of concussion and head injury to student-athletes, including the risks of continuing to play after concussion or head injury, and the symptoms of sudden cardiac arrest.
Acknowledgement as a Parent/Guardian
I, as the parent or legal guardian of the above-named student, have received and read both of the fact sheets regarding concussion and sudden cardiac arrest. I understand the nature and risk of concussion and head injury to student-athletes, including the risks of continuing to play after concussion or head injury, and the symptoms of sudden cardiac arrest.