Please complete all 3 Separate Forms before your child participates in Summer Night Sports.
All 3 forms must be completed and signed by a parent or legal guardian.
This is Form 3.

A concussion is a type of traumatic brain injury—or TBI— caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move quickly back and forth. This fast movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging the brain cells.

Sports are a great way for children and teens to stay healthy and can help them do well in school. To help lower your children's or teens' chances of getting a concussion or other serious brain injury, you should:

• Help create a culture of safety for the team.
  • Work with their coach to teach ways to lower the chances of getting a concussion.
  • Talk with your children or teens about concussion and ask if they have concerns about reporting a concussion. Talk with them about their concerns; emphasize the importance of reporting concussions and taking time to recover from one.
  • Ensure that they follow their coach's rules for safety and the rules of the sport.
  • Tell your children or teens that you expect them to practice good sportsmanship at all times.
• When appropriate for the sport or activity, teach your children or teens that they must wear a helmet to lower the chances of the most serious types of brain or head injury. However, there is no "concussion-proof" helmet. So, even with a helmet, it is important for children and teens to avoid hits to the head.

Children and teens who show or report one or more of the signs and symptoms listed below—or simply say they just "don't feel right" after a bump, blow, or jolt to the head or body—may have a concussion or other serious brain injury.

• Appears dazed or stunned
• Forgets an instruction, is confused about an assignment or position, or is unsure of the 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 or after a hit or fall

• Headache or "pressure" in head
• Nausea or vomiting
• Balance problems or dizziness, or double or blurry vision
• Bothered by light or noise
• Feeling sluggish, hazy, foggy, or groggy
• Confusion, or concentration or memory problems
• Just not "feeling right," or "feeling down"

In rare cases, a dangerous collection of blood (hematoma) may form on the brain after a bump, blow, or jolt to the head or body and can squeeze the brain against the skull. Call 9-1-1 or take your child or teen to the emergency department right away if, after a bump, blow, or jolt to the head or body, he or she has one or more of these danger signs:

• One pupil larger than the other
• Drowsiness or inability to wake up
• A headache that gets worse and does not go away
• Slurred speech, weakness, numbness, or decreased coordination
• Repeated vomiting or nausea, convulsions or seizures (shaking or twitching)
• Unusual behavior, increased confusion, restlessness, or agitation
• Loss of consciousness (passed out/knocked out). Even a brief loss of consciousness should be taken seriously

As a parent, if you think your child or teen may have a concussion, you should:

1. Remove your child or teen from play.
2. Keep your child or teen out of play the day of the injury. Your child or teen should be seen by a healthcare provider and only return to play with permission from a healthcare provider who is experienced in evaluating for concussion.
3. Ask your child's or teen's healthcare provider for written instructions on helping your child or teen return to school. You can give the instructions to your child's or teen's school nurse and teacher(s) and return-to-play instructions to the coach and/or athletic trainer.

Do not try to judge the severity of the injury yourself. Only a healthcare provider should assess a child or teen for a possible concussion. Concussion signs and symptoms often show up soon after the injury. But you may not know how serious the concussion is at first, and some symptoms may not show up for hours or days.

The brain needs time to heal after a concussion. A child's or teen's return to school and sports should be a gradual process that is carefully managed and monitored by a healthcare provider.

For more information, please visit cdc.gov/HEADSUP

Discuss the risks of concussions and other serious brain injuries with your child or teen, and have each person sign below. Please print and keep this information sheet to use at your children's or teens' games and practices to help protect them from a concussion or other serious brain injury.

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