CONCUSSION ACKNOWLEDGEMENT AND SIGNATURE FORM FOR STUDENTS

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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.

High School Students - please read the attached 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.  After reading the fact sheet, please fill out the form below. The form acknowledgement will be kept in the athletics office. 

(Trouble viewing the online fact sheet? Download the PDF by clicking here.)

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

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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: www.cdc.gov/Concussion.
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL AND PREVENTION

 

Concussion Acknowledgement/Signature - Students

STUDENT INFORMATION
Student Grade
MY SPORT
Fall
Winter
Spring
STUDENT - CONCUSSION ACKNOWLEDGEMENT

I am a student athlete participating in the above mentioned sport. I have received and read the Student Athlete Information Fact Sheet. 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.