Concussion Acknowledgement

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A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by bump, blow, or jolt to the head or body that causes the head and brain to move rapidly back and forth. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious.

Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury. If an athlete reports one or more symptoms of concussion listed below after a bump, blow, or jolt to the head or body, s/he should be kept out of play the day of the injury and until a healthcare professional, experienced in evaluating for concussion, says s/he is symptom-free and it’s OK to return to play.

Did You Know? Most concussions occur without loss of consciousness. Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion. Young children and teens are more likely to get a concussion and take longer to recover than adults.

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Please indicate EVERY sport you give permission for your child to participate in this school year. *

Co-Ed Soccer (FALL)

Girls Soccer (FALL)

Cross Country (FALL)

Boys Basketball (Fall)

Volleyball (Fall/Winter)

Girls Basketball (Winter)

Other:

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Parents Name (first and last) *

Student's Name (first and last) *

I acknowledge I have read the "signs" (those observed by the coach) and the symptomes (those reported by athletes). *

Yes

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Concussion Danger Signs: In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention if after a bump, blow, or jolt to the head or body they exhibits any of the following danger signs: *

I acknowledge I have reviewed the concussion danger signs and shared them with my student

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Why Should An Athlete Report Their Symptoms? If an athlete has a concussion, his/her brain needs time to heal. While an athlete’s brain is still healing, they are much more likely to have another concussion. Repeat concussions can: increase the time it takes to recover, result in brain swelling, or in permanent brain damage. They can even be fatal. *

I acknowledge that I have reviewed the reasons an athlete should report their concussion symptoms

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What Should You Do If You Think Your Athlete Has A Concussion? If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. They should be seen by a healthcare professional experienced in evaluating for concussion. The healthcare professional must certify they are symptom-free and OK to return to play. *

I acknowledge my athlete should be seen by a healthcare professional when experiencing concussion symptoms

My student needs to be cleared by a healthcare professional prior to further participation in sports.

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I understand that a coach may determine that an athlete's symptoms requires further evaluation. In those cases, the athlete may not return to play until cleared by a medical professional. *

Yes

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Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration such as studying, working on the computer, or playing video games, may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional. *

I understand the keys to my student recovering from a concussion and that a healthcare professional should manage their care.

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Student Signature: I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY ENTERING MY NAME (E-SIGNATURE) IN THE BOX BELOW, I (the student) CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND WISH TO PARTICIPATE. *

Parent Signature: I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW (E-SIGNATURE), I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND WISH TO PARTICIPATE. *

Submission of Document *

By submitting this document, this submission constitutes my (the parent) and my student's e-signature so they may participate in Conway School's Athletic Program.

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Send me a copy of my responses.

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