Concussion Notification Form
Adapted from the Centers for Disease Control Heads Up Concussion in Youth Sports
Please have both parent and player fill out
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Player's Name: *
Birthdate: *
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Gender *
Event: *
Event Date: *
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Name of Player's Team: *
U-Age:
The above named Player may have sustained a concussion during the above listed event. Any athlete that sustains a bump, blow, jolt to the head, or a blow to another part of the body with the force transmitted to the head and/or is exhibiting signs and symptoms of concussion MUST be removed from play immediately. Even though most concussions appear mild, all concussions are serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. 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. In other words, even a “ding” or slight bump on the head can be serious. Concussions are invisible and most concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or may 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 immediately. For the latest information about concussions and symptoms, visit: www.cdc.gov/ConcussionInYouthSports/
Since the Player may have sustained a concussion, the player has been removed from the game. Please be advised that if a concussion is diagnosed, the Player may not return to play and must obtain and submit a signed clearance from a medical doctor or doctor of osteopathy who specializes in concussion treatment and management. Remember, it’s better to miss one game than to jeopardize the child’s playing career. When in doubt, sit them out!
By my submission below, I acknowledge that I have received a copy of this Form and agree that I have read and understand the information contained in this Form. Provide your Name: *
Date Signed: *
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