PARENTS - Concussion/Head Injury and Sudden Cardiac Arrest Acknowledgement Form


 IC 20-34-7 and IC 20-34-8 require schools to distribute information sheets to inform and educate student athletes and their parents on the nature and risk of concussion, head injury and sudden cardiac arrest to student athletes, including the risks of continuing to play after concussion or head injury.

These laws require that each year, before beginning practice for an interscholastic or intramural sport, a 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.

IC 20-34-7 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.

IC 20-34-8 states that a student athlete who is suspected of experiencing symptoms of sudden cardiac arrest shall be removed from play and may not return to play until the coach has received verbal permission from a parent or legal guardian of the student athlete to return to play. Within 24 hours, this verbal permission must be replaced by a written statement from the parent or guardian.


1. Please read the  “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.

2. After reading the fact sheet, click on the next tab below to read Sudden Cardiac Arrest and Student Athletes.

3. Then fill out the form below. The form acknowledgement will be kept in the athletics office for the 2015-2016 athletics seasons.

4. Make sure your student athlete goes to the Student page and reads the student information and fills out the student form. (Parents - do not fill out the student form for them).  

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


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:




A Fact Sheet for Parents


Sudden cardiac arrest is a rare, but tragic event that claims the lives of approximately 500 athletes each year in the United States. Sudden cardiac arrest can affect all levels of athletes, in all sports, and in all age levels. The majority of cardiac arrests are due to congenital (inherited) heart defects. However, sudden cardiac arrest can also occur after a person experiences an illness which has caused an inflammation to the heart or after a direct blow to the chest.


There may not be any noticeable symptoms before a person experiences loss of consciousness and a full cardiac arrest (no pulse and no breathing). 

Warning signs can include a complaint of:

  • Chest Discomfort
  • Unusual Shortness of Breath
  • Racing or Irregular Heartbeat
  • Fainting or Passing Out


  • If a person experiences any of the following signs, call EMS (911) immediately:
  • If an athlete collapses suddenly during competition
  • If a blow to the chest from a ball, puck or another player precedes an athlete’s complaints of any of the warning signs of sudden cardiac arrest
  • If an athlete does not look or feel right and you are just not sure


How can I help my child prevent a sudden cardiac arrest?

Daily physical activity, proper nutrition, and  adequate sleep are all important aspects of lifelong  health. Additionally, parents can assist  student athletes prevent a sudden cardiac  arrest by:
  • Ensuring your child knows about any  family history of sudden cardiac arrest  (onset of heart disease in a family  member before the age of 50 or a  sudden, unexplained death at an early
  • age)
  • Ensuring your child has a thorough preseason  screening exam prior to  participation in an organized athletic  activity
  • Asking if your school and the site of  competition has an automatic  defibrillator (AED) that is close by and  properly maintained
  • Learning CPR yourself
  • Ensuring your child is not using any  non-prescribed stimulants or  performance enhancing drugs
  • Being aware that the inappropriate use  of prescription medications or energy  drinks can increase risk
  • Encouraging your child to be honest  and report symptoms of chest  discomfort, unusual shortness of  breath, racing or irregular heartbeat, or  feeling faint

What should I do if I think my child has  warning signs that may lead to sudden cardiac  arrest?

1. Tell your child’s coach about any previous events or family history
2. Keep your child out of play
3. Seek medical attention right away


Developed and Reviewed by the Indiana Department of Education’s Sudden Cardiac Arrest Advisory Board (1-7-15)


Concussion/Head Injury and Sudden Cardiac Arrest -