Wollongong Concussion Declaration and Contact Consent

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Contact Sport Parent Declaration & Acknowledgement – to be completed by parents the day before participation.

Email *

Child's Name (First and Surname) *

Parent's name/s (First and Surname) *

School attended *

Sporting event attending *

I give permission for my child to attend and participate in the Diocese of Wollongong Rugby League trials and will participate in the trial in accordance with the compulsory use of a mouthguard. *

Yes

I acknowledge my child has the skills and playing background to attend and participate safely in Rugby League. That they will be trialling in a combined age group of two years and I acknowledge the increased risk of this trial format *

Yes

My child has sustained a concussion in the last 19 days *

Yes

My child has sustained a concussion and has been cleared by a doctor/neurologist to return to play (after 19 days). If so please email preecek01@dow.catholic.edu.au a copy of the clearance. *

Yes

Not Applicable

In the case that my child has any underlying medical conditions,
o I have detailed these conditions in their online CSNSW Sport portal profile (website registration)
o I acknowledge the additional risks associated with my child’s participation in contact and collision sports

*

Yes

Not Applicable

I give permission for my child to receive appropriate medical attention should the need arise *

Yes

I am aware and understand that students sustaining suspected concussion, in accordance with Sports Medicine Australia guidelines, will not be permitted to further participate in the attending trials.

*

I agree

I disagree

A copy of your responses will be emailed to the address you provided.

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