CONCUSSION ACKNOWLEDGEMENT AND SIGNATURE FORM FOR PARENTS

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Due to the new law “Student Athletes: Concussions and Head Injuries” (IC 20-34-7), schools are now required to distribute information sheets to inform and educate student athletes and their parents of the nature and risk of concussion and head injury to student athletes, including the risks of continuing to play after concussion or head injury.

 The law requires that each year, before beginning practice for an interscholastic or intramural sport, a high school student athlete and the student athlete’s parents must be given an information sheet, and both must sign and return a form acknowledging receipt of the information to the student athlete’s coach.

 The law further states that a high school athlete who is suspected of sustaining a concussion or head injury in a practice or game, shall be removed from play at the time of injury and may not return to play until the student athlete has received a written clearance from a licensed health care provider trained in the evaluation and management of concussions and head injuries.

Parent - please read the attached “Heads Up – Concussion in High School Sports – A Fact Sheet for Parents” by clicking on the tab below to read the info online - the information will expand on your screen. After reading the fact sheet, please fill out the form below. The form acknowledgement will be kept in the athletics office.

(Trouble seeing the online Fact Sheet? Click here)

PARENTS CLICK HERE TO READ: Heads Up Concussion in High School Sports - A Fact Sheet for Parents

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What is a concussion?

A concussion is a brain injury. Concussions are caused by a bump, blow, or jolt to the head or body. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious.

What are the signs and symptoms?

You can’t see a concussion. Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days after the injury. If your teen reports one or more symptoms of concussion listed below, or if you notice the symptoms yourself, keep your teen out of play and seek medical attention right away.

Signs Observed by Parents or Guardians
  • Appears dazed or stunned
  • Is confused about assignment or position
  • Forgets an instruction
  • Is unsure of game, score, or opponent
  • Moves clumsily
  • Answers questions slowly
  • Loses consciousness (even briefly)
  • Shows mood, behavior, or personality changes
  • Can’t recall events prior to hit or fall
  • Can’t recall events after hit or fall
Symptoms Reported by Athlete
  • Headache or “pressure” in head
  • Nausea or vomiting
  • Balance problems or dizziness
  • Double or blurry vision
  • Sensitivity to light or noise
  • Feeling sluggish, hazy, foggy  or groggy
  • Concentration or memory problems
  • Confusion
  • Just not “feeling right” or is “feeling down”


How can you help your teen prevent a concussion?

Every sport is different, but there are steps your teens can take to protect themselves from concussion and other injuries.

  • Make sure they wear the right protective equipment for their activity. It should fit properly, be well maintained, and be worn consistently and correctly.
  • Ensure that they follow their coaches' rules for safety and the rules of the sport.
  • Encourage them to practice good sportsmanship at all times.

What should you do if you think your teen has a concussion?

  1. Keep your teen out of play.If your teen has a concussion,her/his brain needs time to heal. Don’t let your teen return to play the day of the injury and until a health care professional, experienced in evaluating for concussion,says your teen is symptom-free and it’s OK to return to play. A repeat concussion that occurs before the brain recovers from the first—usually within a short period of time (hours, days, or weeks)—can slow recovery or increase the likelihood of having long-term problems. In rare cases,repeat concussions can result in edema (brain swelling),permanent brain damage, and even death.
  2. Seek medical attention right away.A health care professional experienced in evaluating for concussion will be able to decide how serious the concussion is and when it is safe for your teen to return to sports.
  3. Teach your teen that it’s not smart to play with a concussion.Rest is key after a concussion. Sometimes athletes wrongly believe that it shows strength and courage to play injured.Discourage others from pressuring injured athletes to play. Don’t let your teen convince you that s/he’s “just fine.”
  4. Tell all of your teen’s coaches and the student’s school nurse about ANY concussion.Coaches, school nurses, and other school staff should know if your teen has ever had a concussion.Your teen may need to limit activities while s/he is recovering from a concussion. Things such as studying, driving, working on a computer, playing video games, or exercising may cause concussion symptoms to reappear or get worse. Talk to your health care professional, as well as your teen’s coaches,school nurse, and teachers. If needed, they can help adjust your teen’s school activities during her/his recovery.

If you think your teen has a concussion: Don’t assess it yourself. Take him/her out of play. Seek the advice of a health care professional.

 It’s better to miss one game than the whole season. 

For more information and to order additional materials free-of-charge, visit: www.cdc.gov/Concussion.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL AND PREVENTION


Concussion Acknowledgement/Signature - Parents

PARENT INFORMATION
STUDENT INFORMATION
Athlete's Grade
Fall Sport
Winter Sport
Spring Sport
PARENT - CONCUSSION ACKNOWLEDGEMENT

I, as the parent or legal guardian of the above named student, have received and read the Parent Information Fact Sheet included on this web page. I understand the nature and risk of concussion and head injury to student athletes, including the risks of continuing to play after concussion or head injury. Please check the "Yes" button to agree with this statement and type your electronic signature in the field provided.

Please check "Yes" to agree with the above statement.