As a parent or guardian of a child who wishes to participate in the Du Quoin Community Unit School District #300 athletic program, I do hereby acknowledge that I have been advised that the Du Quoin Community Unit School District #300 does not maintain any medical insurance which may be available to pay health care costs of any kind incurred by me or my child as a result of injuries to my child as a participant in the Unit athletic program.  I further hereby acknowledge that medical insurance is currently in force and effect which will pay for health care costs which may be incurred as a result of physical injuries which may be sustained by my child as a participant in the Du Quoin Community Unit School District #300 athletic program.  I further understand and hereby acknowledge that I will cause such insurance to be maintained over the full period of time that my child is a participant in the Du Quoin Community Unit School District #300 athletic program.  I understand that in the event that such insurance that I maintain in force and effect does not pay all health care charges as a result of physical injuries which may be sustained by my child that I may be required to pay such charges out of my own pocket ant that neither the Du Quoin Community Unit School District #300 nor any of its officers, agents, servants or employees will have any obligation whatsoever to all or any part of such charges.

Student Athlete Concussions and Head Injuries

Student athletes must comply with Illinois’ Youth Sports Concussion Safety Act and all protocols, policies and bylaws of the Illinois High School Association  before being allowed to participate in any athletic activity, including practice or competition.

A student who was removed from practice or competition because of a suspected concussion shall be allowed to return only after all statutory prerequisites are completed, including without limitation, the School District’s return-to-play and return-to-learn protocols.

Concussion Information-
A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow,
or jolt to the head, or by a blow to another part of the body with the force transmitted to the head.
They can range from mild to severe and can disrupt the way the brain normally works. Even
though most concussions are mild, all concussions are potentially serious and may result in
complications including prolonged brain damage and death if not recognized and
managed properly. In other words, even a “ding” or a bump on the head can be serious. You
can’t see a concussion and most sports concussions occur without loss of consciousness. Signs
and symptoms of concussion may show up right after the injury or can take hours or days to fully
appear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs
of concussion yourself, seek medical attention right away.
Symptoms may include one or more of the following:
 Headaches
 “Pressure in head”
 Nausea or vomiting
 Neck pain
 Balance problems or dizziness
 Blurred, double, or fuzzy vision
 Sensitivity to light or noise
 Feeling sluggish or slowed down
 Feeling foggy or groggy
 Drowsiness
 Change in sleep patterns
 Amnesia
 “Don’t feel right”
 Fatigue or low energy
 Sadness
 Nervousness or anxiety
 Irritability
 More emotional
 Confusion
 Concentration or memory problems
(forgetting game plays)
 Repeating the same
question/comment
Signs observed by teammates, parents and coaches include:
 Appears dazed
 Vacant facial expression
 Confused about assignment
 Forgets plays
 Is unsure of game, score, or opponent
 Moves clumsily or displays incoordination
 Answers questions slowly
 Slurred speech
 Shows behavior or personality changes
 Can’t recall events prior to hit
 Can’t recall events after hit
 Seizures or convulsions
 Any change in typical behavior or personality
 Loses consciousness

Student/Parent Consent and Acknowledgements
By electronically signing this form, we acknowledge we have been provided information regarding concussion policy.