Acknowledgement of Risk:

I am aware that with participation in sports comes the risk of injury to my child. I acknowledge and fully understand that my child will be engaging in activities which involve risk of injury. The injury could be serious or catastrophic including permanent disability. I assume all the foregoing risk and accept personal responsibility for damages following such injury, permanent disability or death.

Consent to Treat Statement:

In the event of my absence and if, in the judgment of any representative(s) of Richland 44, the above student-athlete needs immediate care and treatment as a result of any injury or sickness, I do hereby request, authorize and consent to such care and treatment as may be given to said student-athlete by any physician; athletic trainer, nurse, hospital, or school representative for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures; treatment procedures, operative procedures and x-ray treatment of the/above student-athlete. The INSURANCE policy listed below will be used to pay for our child. However I understand and agree to accept responsibility for all payments and agree that Richland 44 School District bear NO responsibility for any medical expenses.

If a parent/legal guardian cannot be reached, please indicate an additional adult you wish to be contacted for emergency purposes that have authority to make decisions for your child in your absence.

By signing below, I hereby certify that I have read and fully understand the Acknowledgement of Risk and Consent to Treat Statement and agree to follow them.

CONCUSSION FACT SHEET FOR PARENTS

What is a concussion?

A concussion is a brain injury. Concussions are caused by a bump, blow, or jolt to the head or body, Even or what seems to be a mild bump or blow to the head can be serious.

What are the signs and symptoms?

You can't see a concussion, Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days after the injury. If your teen reports, one or more symptoms of concussion listed below, or if you notice the symptoms yourself, keep your teen out of play and seek medical attention right away.

Signs Observed By Parents or Guardians

• Appears dazed or stunned
• Is confused about assignment or position
• Forgets an instruction
• Is unsure of game, score, or opponent
• Moves clumsily
• Answers questions slowly
• Loses consciousness (even briefly)
• Shows mood, behavior, or personality changes
• Can't recall events prior to hit or fall
• Can't recall events after hit or fall

Symptoms Reported by Athlete  

• Headache or "pressure" in head  
• Nausea or vomiting  
• Balance problems or dizziness  
• Double or blurry vision
• Sensitivity to light or noise  
• Feeling stuggish, hazy, foggy, or groggy  
• Concentration or memory problems
• Confusion
• Just not "feeling right" or is "feeling down"   

 

How can you help your teen prevent a concussion?

Every sport is different, but there are steps your teens can take to protect themselves from concussion and other injuries.

• Make sure they wear the right protective equipment for their activity. it should fit properly, be well maintained, and be worn consistently and correctly.
• Ensure that they follow their coaches' rules for safety and the rules of the sport
• Encourage them to practice good sportsmanship at all times.

 

What should you do if you think your teen has a concussion?

1.Keep your teen out of play. If your teen has a concussion, her/his brain needs time to heal. Don't let your teen return to play the day of the injury and until a health care professional, experienced in evaluating for concussion, says your teen is symptom-free and it's OK to return to play. A repeat concussion that occurs before the brain recovers from the first - usually within a short period of time (hours, days, or weeks) - can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in edema (brain swelling), permanent brain damage, and even death.

2.Seek medical attention right away. A health care professional experienced in evaluating for concussion will be able to decide how serious the concussion is and when it is safe for your teen to return to sports.

3.Teach your teen that it's not smart to play with a concussion. Rest is key after a concussion. Sometimes athletes wrongly believe that it shows strength and courage to play injured. Discourage others from pressuring injured athletes to play. Don't let your teen convince you that s/he's "just fine".

4.Tell all of your teen's coaches and the student's school nurse about ANY concussion. Coaches, school nurses, and other school staff should know if your teen has ever had a concussion. Your teen may need to limit activities while s/he is recovering from a concussion Things such as studying, driving, working on a computer, playing video games, or exercising may cause concussion symptoms to reappear or get worse. Talk to your health care professional, as well as your teen's coaches, school nurse, and teachers. If needed, they can help adjust your teen's school activities during her/his recovery.

THIS FORM MUST BE SIGNED ANNUALLY AND MUST BE AVAILABLE FOR INSPECTION AT THE SCHOOL

What is (I concussion?

A concussion is a brain injury that:

• Is caused by a bump, blow, or jolt to the head or body
• Can change the way your brain normally works
• Can occur during practices or games in any sport or recreational activity
• Can happen even if you haven't been knocked out
• Can be serious even if you've just been "dinged" or "had your bell rung"

All concussions are serious. A concussion can affect your ability to do schoolwork and other activities (such as playing video games, working on a computer, studying, driving, or exercising). Most people with a concussion get better, but it is important to give your brain time to heal.

What are the symptoms of a concussion?

You can't see a concussion, but you might notice one or more of the symptoms listed below or that you "don't feel right" soon after, a few days after, or even weeks after the injury.

• Headache or "pressure" in head
• Nausea or vomiting
• Balance problems or dizziness
• Double or blurry vision
• Bothered by light or noise
• Feeling sluggish, hazy, foggy, or groggy
• Difficulty paying attention
• Memory problems
• Confusion

What should I do if I think I have a concussion?

• Tell your coaches and your parents. Never ignore a bump or blow to the head even if you feel fine. Also, tell your coach right away if you think you have a concussion or if one of your teammates might have a concussion.
• Get a medical check-up. A doctor or other health care professional can tell if you have a concussion and when it is OK to return to play.
• Give yourself time to get better. If you have a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have another concussion. Repeat concussions can increase the time it takes for you to recover and may cause more damage to your brain. It is important to rest and not return to play until you get the OK from your health care professional that you are symptom-free.

How can I prevent a concussion?

• Every sport is different, but there are steps you can take to protect yourself.
• Use the proper sports equipment, including personal protective equipment. In order for equipment to protect you, it must be:
  • The right equipment for the game, position, or activity
  • Worn correctly and the correct size and fit
  • Used every time you play or practice
• Follow you coach's rules for safety and the rules of the sport
• Practice good sportsmanship at all times

By signing below, both student-athlete and parent/guardian acknowledge they have read and understand the facts about concussions.