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Concussion Agreement Form

Concussion Agreement Form

Each student and his or her parent/guardian must read and sign this Agreement to Participate each year before being allowed to participate in interscholastic sports or intramural athletics.

Student Information

Main Contact Information

PLEASE READ AND AGREE TO THE FOLLOWING:


1. The above-named student wishes to participate in the following interscholastic sports or intramural athletics:

2. Before the student will be allowed to participate, the student must provide the School District with a certificate of physical fitness (if participating in interscholastic sport(s), the Pre-Participation Physical Examination Form serves this purpose), show proof of accident insurance coverage, and complete any forms required by the relevant athletic association (e.g., the Illinois High School Association (IHSA)).

3. The student and the student's parent/guardian agree that the student will abide by all conduct rules and will behave in a sportsmanlike manner. They further agree that the student will follow the coaches' instructions, playing techniques, and training schedule as well as all safety rules.

4. The student and the student's parent/guardian understand that Board policy 7:305, Student Athlete Concussions and Head Injuries, requires, among other things, that a student athlete who exhibits signs and symptoms, or behaviors consistent with a concussion or head injury must be removed from participation or competition at that time and that such student will not be allowed to return to play unless cleared to do so by a physician licensed to practice medicine in all its branches or a certified athletic trainer.

5. Below is a Concussion Information Sheet, which is written information explaining concussion prevention, symptoms, treatment, and guidelines, and includes guidelines for safely resuming participation in an athletic activity following a concussion.

6. The student and the student's parent/guardian are aware that with participation in sports comes the risk of injury, and that the degree of danger and seriousness of risk vary significantly from one sport to another, with contact sports carrying the highest risk. The student and the student's parent/guardian are aware that participating in sports involves travel with the team. The student and the student's parent/guardian acknowledge and accept the risks inherent in the sports or athletics in which the student will be participating and in all travel involved. The student and the student's parent/guardian agree to indemnify and hold the District, its employees, agents, coaches, School Board members, and volunteers harmless from any and all liability, actions, claims, or demands of any kind and nature whatsoever that may arise by or in connection with the student participating in the school-sponsored interscholastic sports or intramural athletics, to the extent allowed by law, including relating to physical injury to the student or others while participating in the above indicated sport or activity. The terms hereof shall serve as a release and assumption of risk for the student and the student's parent/guardian and their heirs, estate, executor, Administrator, assignees, and for all members of the student and the student's parent/guardian's family. The parent/guardian certifies that the student is in good physical health and is capable of participation in the above indicated sport or activity.

7. If any term, covenant, condition, or provision of this Agreement is held by a court of competent jurisdiction to be invalid, void, or unenforceable, the remainder of the provisions shall remain in full force and effect and shall in no way be affected, impaired, or invalidated.

Concussion Information Sheet

Board Policy 7:305, Concussions and Head Injuries, requires, among other things, that a student athlete who exhibits signs and symptoms, or behaviors consistent with a concussion or head injury must be removed from participation or competition at that time and that such student will not be allowed to return to play unless cleared to do so by a physician licensed to practice medicine in all its branches or a certified athletic trainer.

This form must be given to a student and their parent guardian each year with the Agreement to Participate. The Agreement to Participate must be completed and signed each year by the student and the student's parent (meaning the student's natural or adoptive parent or other legal guardian or person with legal authority to make medical decisions for the student) before the student may participate in interscholastic sports or intramural athletics for the school year. This form contains all language from the Concussion Information Sheet approved by the Illinois High School Association.

Concussion Information

A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. In other words, even a "ding" or a bump on the head can be serious. You can't see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away.

Symptoms may include one or more of the following:

  • Headaches
  • "Pressure in head"
  • Nausea or vomiting
  • Neck pain
  • Balance problems or dizziness
  • Blurred, double, or fuzzy vision
  • Sensitivity to light or noise
  • Feeling sluggish or slowed down
  • Feeling foggy or groggy
  • Drowsiness
  • Change in sleep patterns
  • Amnesia
  • "Don't feel right"
  • Fatigue or low energy
  • Sadness
  • Nervousness or anxiety
  • Irritability
  • More emotional
  • Confusion
  • Concentration or memory problems (forgettinggame plays)
  • Repeating the same question/comment

Signs observed by teammates, parents and coaches include:

  • Appears dazed
  • Vacant facial expression
  • Confused about assignment
  • Forgets plays
  • Is unsure of game, score, or opponent
  • Moves clumsily or displays incoordination
  • Answers questions slowly
  • Slurred speech
  • Shows behavior or personality changes
  • Can't recall events prior to hit
  • Can't recall events after hit
  • Seizures or convulsions
  • Any change in typical behavior or personality
  • Loses consciousness

What can happen if my child keeps on playing with a concussion or returns too soon?

Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that adolescent or teenage athletes will often fail to report symptoms of injuries. Concussions are no different. As a result, education of Administrators, coaches, parents and students is the key to student-athlete's safety.

If you think your child has suffered a concussion

Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately. No athlete may return to play or physical activity, including the physical activity portion of physical education courses, after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for several hours. IHSA Policy requires athletes to provide their school with written clearance from either a physician licensed to practice medicine in all its branches or a certified athletic trainer working in conjunction with a physician licensed to practice medicine in all its branches prior to returning to play or practice following a concussion or after being removed from an interscholastic contest due to a possible head injury or concussion and not cleared to return to that same contest. In accordance with state law, all IHSA member schools are required to follow this policy. Board policy requires the same clearance before such a student can return to intramural athletics and the physical activity portion of a physical education class.

You should also inform your child's coach if you think that your child may have a concussion, even if it resulted from an injury that occurred outside of school/school activities. Remember it's better to miss one game than miss the whole season. And when in doubt, the athlete sits out.

How can you help your child prevent a concussion or other serious brain injury?

  • Ensure that they follow their coach's rules for safety and the rules of the sport.
  • Encourage them to practice good sportsmanship at all times.
  • Make sure they wear the right protective equipment for their activity. Protective equipment should fit properly andbe well maintained.
  • Wearing a helmet is a must to reduce the risk of a serious brain injury or skull fracture.
  • However, helmets are not designed to prevent concussions. There is no "concussion-proof" helmet. So, even with ahelmet, it is important for kids and teens to avoid hits to the head.
  • Tell your child's coaches if your child had a previous concussion. Your child's coach may not know about aconcussion your child received in another sport or activity unless you tell the coach.

For current and up-to-date information on concussions you can go to: http://www.cdc.gov/ConcussionInYouthSports/

Adapted from the IHSA Sports Medicine Acknowledgement & Consent Form, which is adapted from the CDC and the 3rd International Conference on Concussion in Sport

By checking the boxes below, the student and the student's parent/guardian indicate that they have read the above Agreement to Participate and the enclosed Concussion Information Sheet, and that they understand and agree to abide and be bound by the terms of this text.