EmailMe Form - LS - Parent/Student-Athlete Concussion Statement

Student's Name *

First Last

Please check the following statements acknowledging that you and your child understand *

I understand that it is my responsibility to report all injuries and illnesses to my coach, athletic trainer, and/or team physician.

I have watched the necessary informational video and understand the back information presented.

Please check *

A concussion is a brain injury, which I am responsible for reporting to my coach, athletic trainer, or team physician.

Please check *

A concussion can affect my ability to perform everyday activities, and affect reaction time, balance, sleep and classroom performance.

Please check *

You cannot see a concession, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury.

Please check *

If I suspect a teammate has a concussion, I am responsible for reporting the injury to my coach, athletic trainer, or team physician.

Please check *

I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion-related symptoms.

Please check *

Following concussion the brain needs time to heal. You are much more likely to have a repeat concussion if you return to play before your symptoms resolve.

Please check *

In rare cases, repeat concussions can cause permanent brain damage, and even death.

Parent's Signature *

Clear

Parent's Printed Name *

First Last

Date Time *

MM / DD / YYYY

Student's Signature *

Clear

Student's Printed Name *

First Last

Date Time *

MM / DD / YYYY