Student/Parent Concussion Awareness Form

Student/Parent Concussion Awareness Form

    Student-Athlete & Parent/Legal Custodian Concussion Statement

    Concussions at all levels of sports have received a great deal of attention and a state law has been passed to address this issue. Adolescent athletes are particularly vulnerable to the effects of concussion. Once considered little more than a minor "ding" to the head, it is now understood that a concussion has the potential to result in death or changes in brain function (either short-term or long term). A concussion is a brain injury that results in a temporary disruption of normal brain function. A concussion occurs when the brain is violently rocked back and forth or twisted inside the skull as a result of a blow to the head or body. Continued participation in any sport following a concussion can lead to worsening concussion symptoms, as well as increased risk for further injury to the brain, and even death. Player and parental education in this area is crucial - that is the reason for this document.

    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 black out 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 black 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
    Taking longer to figure things out
    Difficulty concentrating
    Difficulty remembering new information
    Fuzzy or blurry vision
    Feeling sick to your stomach/queasy
    Vomiting/throwing up
    Balance problems
    Sensitivity to noise or light
    Irritability-things bother you more easily
    Being more moody
    Feeling nervous or worried
    Crying more
    Sleeping more than usual
    Sleeping less than usual
    Trouble falling asleep
    Feeling tired

    Table is adapted from the Centers for Disease Control and Prevention (

    What should I do if I think a student-athlete has sustained a concussion? If you suspect a student-athlete is experiencing any of the signs and symptoms listed above, you immediately remove them from participation, let their parents know, and/or refer them to the appropriate medical personnel.

    What are the warning signs that a more significant head injury may have occured? If they have a headache that gets worse over time, experience loss of coordination or abnormal body movements, have repeated nausea, vomiting, slurred speech, or you witness what you believe to be a severe head impact, you should refer them to appropriate medical personnel immediately.

    What are some of the long-term or cumulative issues that may result from a concussion? Individuals may have trouble in some of their classes at school or even with activities at home. Down the road, especially if their injury is not managed properly, or if they return to play too early, the may experience issues such as being depressed, not feeling well, of have trouble remembering things for a long time. Once an individual has a concussion, they are also more likely to sustain another concussion.

    How do I know when it's ok for a student-athlete to return to participation after a suspected concussion? Any student-athlete experiencing signs and symptoms consistent with a concussion should be immediately removed from play or practice and referred to appropriate medical personnel. They should not be returned to play or practice on the same day. To return to play or practice, they will need written clearance from a medical professional trained in concussion management.

    If there is anything on this sheet that you do not understand, please ask a coach/staff member to explain or read it to you.

    Student-Athlete Name:
    Parent/Legal Custodian names:

    Yes. We have read the Student-Athlete & Parent/Legal Custodian Concussion Information Sheet.

    1. A concussion is a brain injury, which should be reported to my parents, my coach(es), or a medical professional if one is available.

    2. A concussion can affect the ability to perform everyday activities such as the ability to think, balance, and classroom performance.

    3. A concussion cannot be “seen.” Some symptoms might be present right away. Other symptoms can show up hours or days after an injury.

    4. I will tell my parents, my coach, and/or a medical professional about my injuries and illnesses.

    5. If I think a teammate has a concussion, I should tell my coach(es), parents, or medical professional about the concussion.

    6. I will not return to play in a game or practice if a hit to my head or body causes any concussion-related symptoms.

    7. 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.

    8. 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.

    9. I realize that ER/Urgent Care physicians will not provide clearance if seen right away after the injury.

    10. 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.

    11. Sometimes, repeat concussions can cause serious and long-lasting problems.

    12. I have read the concussion symptoms on the Concussion Information Sheet.

    SCISA CONCUSSION POLICY: In accordance with South Carolina/Georgia law and national playing rules published by the National Federation of State High School Associations, any athlete who exhibits signs, symptoms, or behaviors consistent with a concussion shall be immediately removed from the practice or contest and shall not return to play until an appropriate health care professional has determined that no concussion has occurred. (NOTE: An appropriate health care professional may include licensed physician (MD/DO) or another licensed individual under the supervision of a licensed physician, such as a nurse practitioner, physician assistant, or certified athletic trainer who has received training in concussion evaluation and management).

    1) No athlete is allowed to return to a game or a practice on the same day that a concussion (a) has been diagnosed, OR (b) cannot be ruled out.

    2) Any athlete diagnosed with a concussion shall be cleared medically by an appropriate health care professional prior to resuming participation in any future practice or contest. The formulation of a gradual return to play protocol shall be a part of the medical clearance.

    3) It is mandatory that every coach in each SCISA sport participate in a free, online course on concussion management prepared by the NFHS and available at every year.

    4) Each school will be responsible for monitoring the participation of its coaches in the concussion management course, and shall keep a record of those who participate.

    Student’s Signature:


    Parent/Legal Custodian Signature: