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2021-22 Parent/Student Concussion Form


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What is a concussion? ​​A concussion is an injury to the brain caused by a direct or indirect blow to the  head. It results in your brain not working as it should. It may or may not cause you to blackout or pass  out. It can happen to you from a fall, a hit to the head, or a hit to the body that causes your head and your  brain to move quickly back and forth. 

How do I know if I have a concussion? ​​There are many signs and symptoms that you may have  following a concussion. A concussion can affect your thinking, the way your body feels, your mood, or  your sleep. Here is what to look for:

Thinking/Remembering Physical Emotional/Mood Sleep

Difficulty thinking clearly
Feeling slowed downDifficulty Concentrating
Difficulty remembering new info

Fuzzy or blurry vision
Balance problems
Sensitivity to noise or light

More emotional than normal
Feeling nervouse or anxious
Crying more
Sleeping more than usual
Sleeping less than usual
Trouble falling asleep

Table from the Centers for Disease Control and Prevention (​https://www.cdc.gov/concussion/​)

What should I do if I think I have a concussion?​​ If you are having any of the signs or symptoms listed  above, you should tell your parents, coach, athletic trainer or school nurse so they can get you the help  you need. If a parent notices these symptoms, they should inform the school nurse or athletic trainer. 

When should I be particularly concerned?​​ If you have a headache that gets worse over time, you are  unable to control your body, you throw up repeatedly or feel more and more sick to your stomach, or your  words are coming out funny/slurred, you should let an adult like your parent or coach or teacher know  right away, so they can get you the help you need before things get any worse. 

What are some of the problems that may affect me after a concussion?​​ You may have trouble in some  of your classes at school or even with activities at home. If you continue to play or return to play too early  with a concussion, you may have long term trouble remembering things or paying attention, headaches  may last a long time, or personality changes can occur Once you have a concussion, you are more likely  to have another concussion. 

How do I know when it’s ok to return to physical activity and my sport after a concussion?​​ After  telling your coach, your parents, and any medical personnel around that you think you have a concussion,  you will probably be seen by a doctor trained in helping people with concussions. Your school and your  parents can help you decide who is best to treat you and help to make the decision on when you should  return to activity/play or practice. Your school will have a policy in place for how to treat concussions.  You should not return to play or practice on the same day as your suspected concussion. 

You should not have any symptoms at rest or during/after activity when you return to play, as this is a sign your brain has not recovered from the injury.

This information is provided to you by the UNC Matthew Gfeller Sport-Related TBI Research Center, North Carolina Medical Society, North
Carolina Athletic Trainers’ Association, Brain Injury Association of North Carolina, North Carolina Neuropsychological Society, and North  Carolina Independent Schools Athletic Association. 


Student-Athlete & Parent/Legal Custodian Concussion Statement

** If there is anything on this form that you do not understand, please ask an adult to explain or read it to you.

This form is to be completed for each student-athlete, even if there are mulitple student-athletes in each household.

Please complete the form below. Required fields marked with an asterisk *

Please select the sport the student-athlete plans on playing each season.
If he/she does not wish to play a sport in a certain season, leave it blank.
If he/she decides at a later date to play an additional sport, there is no need to complete a second form.

Fall Sports
Answer Required
Winter Sports
Answer Required
Please check the box if you also wish to participate in the Shooting Team during the winter
Answer Required
Spring Sports
Answer Required
Answer Required
After reading the information sheet, I am aware of the following information: *
Both acknowledgments are required, unless otherwise stated.
Answer Required
Student-Athlete Acknowledgement
Parent/Legal Custodian Acknowledment
A concussion is a brain injury, which should be reported to my parents, my coach(es), or a medical  professional if one is available. 
A concussion can affect the ability to perform everyday activities such as the ability to think,  balance, and classroom performance. 
A concussion cannot be “seen.” Some symptoms might be present right away. Other symptoms can  show up hours or days after an injury. 
I will tell my parents, my coach, and/or a medical professional about my injuries and illnesses. *only student acknowledgement required
If I think a teammate has a concussion, I should tell my coach(es), parents, or medical professional  about the concussion.  *only student acknowledgement required
I will not return to play in a game or practice if a hit to my head or body causes any  concussion-related symptoms.  *only student acknowledgement required
I will/my child will need written permission from a medical professional trained in concussion  management to return to play or practice after a concussion. 
Based on the latest data, most concussions take days or weeks to get better. A concussion may not  go away right away. I realize that resolution from this injury is a process and may require more  than one medical evaluation. 
I realize that ER/Urgent Care physicians will not provide clearance if seen right away after the  injury.
After a concussion, the brain needs time to heal. I understand that I am/my child is much more  likely to have another concussion or more serious brain injury if return to play or practice occurs  before concussion symptoms go away. 
Sometimes, repeat concussions can cause serious and long-lasting problems. 
I have read the concussion symptoms on the Concussion Information Sheet. 
Student-Athlete Signature:*
Answer Required
Parent/Legal Custodian Signature:*
Answer Required
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