Alaska Youth Soccer Association

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Head Injury and Concussion Return to Play Form- You will use this form if a player has been removed from a game, practice, camp or tournament due to suspicion of a concussion. The player MUST receive a written clearance from a licensed Medical Doctor (MD) or Doctor of Osteopathic Medicine prior to returning to play.
Please complete this Head Injury and Concussion Return to Play Form along with submitting a copy of the medical release to the AYSA office via email to alaskayouthsoccer@gmail.com. Once verified by AYSA, the player pass will be released, and the player’s status will be updated on the online team roster for return to play.

Player Name: *

Player Date of Birth: *

YYYY

Player Club Team: *

Date of Head Injury? *

YYYY

Did you submit the AYSA Head Injury Notification Form *

Yes

Parent/ Guardian Name: *

Parent/ Guardian Phone Number and Email: *

Alaska Youth Soccer Association - State Office Email- alaskayouthsoccer@gmail.com

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