Students - Concussion/Head Injury and Sudden Cardiac Arrest Acknowledement Form

Laws 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.

High School Students: 

1. Please read the Heads Up – Concussion in High School Sports – A Fact Sheet for Athletes by clicking on the tab below - the information will expand on your screen. 

2. Then click on the next tab to read: Sudden Cardiac Arrest - A Fact Sheet for Students. 

3. After reading both fact sheets, please fill out the form below. The form acknowledgement will be kept in the athletics office. 


CLICK HERE STUDENTS TO READ: Heads Up – Concussion in High School Sports – A Fact Sheet for Athletes


What is a concussion?

A concussion is a brain injury that:

  • Is caused by a bump, blow, or jolt to the head or body.
  • Can change the way your brain normally works.•Can occur during practices or games in any sport or recreational activity.
  • Can happen even if you haven’t been knocked out.
  • Can be serious even if you’ve just been “dinged” or “had your bell rung.”

All concussions are serious. A concussion can affect your ability to do schoolwork and other activities (such as playing video games, working on a computer,studying, driving, or exercising). Most people with a concussion get better, but it is important to give your brain time to heal.

What are the symptoms of a concussion?

You can’t see a concussion, but you might notice one or more of the symptoms listed below or that you“don’t feel right” soon after, a few days after, or even weeks after the injury.

  • Headache or “pressure” in head
  • Nausea or vomiting
  • Balance problems or dizziness
  • Double or blurry vision
  • Bothered by light or noise
  • Feeling sluggish, hazy, foggy or groggy
  • Difficulty paying attention
  • Memory problems
  • Confusion

What should I do if I think I have a concussion?

Tell your coaches and your parents.Never ignore a bump or blow to the head even if you feel fine. Also,tell your coach right away if you think you have a concussion or if one of your teammates might have a concussion.

  • Get a medical check-up. A doctor or other healthcare professional can tell if you have a concussion and when it is OK to return to play.
  • Give yourself time to get better. If you have a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have another concussion. Repeat concussions can increase the time it takes for you to recover and may cause more damage to your brain. It is important to rest and not return to play until you get the OK from your health care professional that you are symptom-free.

How can I prevent a concussion?

Every sport is different, but there are steps you can take to protect yourself.

  • Use the proper sports equipment, including personal protective equipment. In order for equipment to protect you, it must be:
    - The right equipment for the game, position, or activity
    - Worn correctly and the correct size and fit
    - Used every time you play or practice
  • Follow your coach’s rules for safety and the rules of the sport.
  • Practice good sportsmanship at all times.

If you think you have a concussion:

Don’t hide it. Report it. Take time to recover.

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

For more information and to order additional materials free-of-charge, visit:






Sudden cardiac arrest can occur even in athletes who are in peak shape. Approximately 500 deaths are attributed to sudden cardiac arrest in 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. Once a cardiac arrest occurs, there is very little time to save the athlete, so identifying those at risk before the arrest occurs is a key factor in prevention.



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 prevent a sudden cardiac arrest?

Daily physical activity, proper nutrition, and adequate sleep are all important aspects of lifelong
health. Additionally, you can assist by:
  • Knowing if you have a 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)
  • Telling your health care provider during  your pre-season physical about any  unusual symptoms of chest discomfort,  shortness of breath, racing or irregular  heartbeat, or feeling faint, especially if
  • you feel these symptoms with physical  activity
  • Taking only prescription drugs that are  prescribed to you by your health care  provider
  • Being aware that the inappropriate use  of prescription medications or energy  drinks can increase your risk
  • Being honest and reporting symptoms  of chest discomfort, unusual shortness  of breath, racing or irregular heartbeat,  or feeling faint  

What should I do if I think I am developing warning signs that may lead to sudden cardiac arrest?

1. Tell an adult – your parent or guardian, your coach, your athletic trainer or your school nurse
2. Get checked out by your health care provider
3. Take care of your heart
4. Remember that the most dangerous thing you can do is to do nothing

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

Concussion/Head Injury & Sudden Cardiac Arrest - S