SHCS Sports Concussion Statement

Student-Athlete & Parent/Legal Custodian Concussion Statement
Please review the concussion information below, then answer the questions that follow.
*If there is anything on the document above that you do not understand, please ask an adult to explain or read it to you.
Student Athlete Name
This form must be completed for each student-athlete, even if there are multiple student-athletes in each household.
Parent/Legal Custodian Name(s)
We have read the Student-Athlete & Parent/Legal Custodian Concussion Information Sheet.

Yes
After reading the information sheet posted above, I am aware of the following information:

(please check appropriate boxes in agreement with the following statements)
A concussion is a brain injury, which should be reported to my parents, my coach(es), or a medical professional if one is available.

Student AthleteParent/Custodian
A concussion can affect the ability to perform everyday activities such as the ability to think, balance, and classroom performance. A concussion cannot be "seen." Some symptoms might be present right away. Other symptoms can show up hours or days after an injury.

Student AthleteParent/Custodian
I will tell my parents, my coach, and/or a medical professional about my injuries and illnesses.

Student Athlete
If I think a teammate has a concussion, I should tell my coach(es), parents, or medical professional about the concussion.

Student Athlete
I will not return to play in a game or practice if a hit to my head or body causes any concussion-related symptoms.

Student Athlete
I will/my child will need written permission from a medical professional trained in concussion management to return to play or practice after a concussion. Based on the latest data, most concussions take days or weeks to get better. A concussion may not go away right away. I realize that resolution from this injury is a process and may require more than one medical evaluation.

Student AthleteParent/Custodian
I realize that ER/Urgent Care physicians will not provide clearance if seen right away after the injury.

Student AthleteParent/Custodian
After a concussion, the brain needs time to heal. I understand that I am/my child is much more likely to have another concussion or more serious brain injury if return to play or practice occurs before concussion symptoms go away.

Student AthleteParent/Custodian
Sometimes, repeat concussions can cause serious and long-lasting problems.

Student AthleteParent/Custodian
I have read the concussion symptoms on the Concussion Information Sheet.
Signature of Student Athlete

Clear
Date

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Today's Date
Signature of Parent/Legal Custodian

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Date

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Today's Date
Should be Empty:

Student-Athlete & Parent/Legal Custodian Concussion Statement