I Understandthatitismyresponsibilitytoreportallmyinjuries Andsymptomsto

DutchForkHighSchoolAthleticTraining

ConcussionResponsibility

I understandthatitismyresponsibilitytoreportallmyinjuries andsymptomsto myparent(s)/guardian(s),athletic trainer,andcoach.It isimportantthat I amanactive participantinmyownhealth.

I haveread andunderstandtheconcussionfactsheets thatI havebeenprovided.

Athlete andparent,pleaseinitialeachlinebelow.

Aconcussionisa braininjury, andI amresponsible forreporting mysymptomstomyparents,athletic trainer, andcoach.

Aconcussioncanaffectmyabilitytoperformeverydayactivities,altermyemotions, andeffectclassroomand athleticperformance.

Imaynoticeoneormoresymptomsimmediatelyafter receivingablowtotheheador body. Othersymptoms canshowuphoursanddays aftertheinjury.

Followingaconcussion, thebrainneedstimetoheal.Physical andmental restisnecessary.I am much more likelytohavea repeated concussionif Ireturntoplaybeforemy symptoms resolve. Itcanalsotakemoretimefor symptomstogoawayif I returntoosoon.

Iwillnotreturntoplayinagameorpracticeif Ihavereceivedablowtothe heador body thatresultsin concussion-related symptoms until Iamcleared toreturnbymyathletictrainer.

If Isuspectateammatehas aconcussion, I amresponsibleforreportingthepossible injurytomyathletictrainer for thegoodofmyteammate.

If I havequestions, Iwill contactmyathletictrainerformoreinformation.

By signingbelow,IacknowledgethatI havereadandunderstandthe informationregardingconcussions. Iknow and understandthatIshouldnotifymyathletictrainer andparents whenIsuspectI mayhavesustainedaconcussion.

Student Athlete Name (Print) / Parent Name (Print)
Student Athlete Signature / Date / Parent Signature / Date