EmailMe Form - Concussion Signature Form

Player Name *

First Last

Player date of birth *

MM / DD / YYYY

Parent / Guardian Name *

First Last

*

	Parent / Guardian Initials	Player Initials
I have read the concussion facts sheet.
A concussion is a brain injury, which I am responsible for reporting to my coach, trainer, or team medical staff.
A concussion can affect my ability to perfomr everyday activities and affect reaction time, balance, sleep, and classroom performance.
I cannot see a concussion, but I might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury.
If i suspect a teammate has a concussion, I am responsible for reporting to my coach, trainer or team medical staff.
I will not return to play in a game or practice if I have recieved a blow to the head or body that results in concussion related symptoms.
Following a concussionthe brain needs time to heal. You are much more likleyto have a repeat concussionif you return to play before your sypmtoms resolve.
In rare cases, repeat concussions can cause permanent brain damage and even death.

Parent signature *

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Parent / Guardian Name *

Date Time

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Student signature *

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Student Name *

Date Time

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